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Waste Tire S ey & Inspection Repor 4nspection Report Number ■ <br /> CalRecycle State of California <br /> CalRecycle 181(Rev. (Cal Survey Form - Page 1 I1 - 1176682 <br /> Dept.of Resources Recycling and Recovery(CalRecycle) <br /> Part A-Survey _ BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- inspection b - Inspection Type(Fill one) <br /> Site Suffix: I C i 7 <br /> _ - ® Routine Q Re-inspection Q Referral Q Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier: - � w Com, , {� Q CHP Q CalRecycle Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name , Inspected By Inspector <br /> _" <br /> ru,'V1 >i k ( }tiu-C-h c <br /> Physical A dress - 1 Q <br /> � � 13�'1-12TI �dv <br /> 1011;_00 <br /> /� Inspection Date Q <br /> Time In Time Out <br /> Business Rep Title ®AM ® AM <br /> ) I , -© Q O PM S O PM <br /> (Fill one only) Fill all that apply) Fill all that apply) Fill all that apply) <br /> --�- - -----{ -- <br /> Operational Status Tire Type � Business Role Storage <br /> e Type <br /> e <br /> Tire Count (Whole/PTE) ( y) ( ppy) ( ppy) ( ppy) <br /> 2- ® Active ® Passenger ® Generator ® Outdoor <br /> GPS Latitude O O Closed Q Altered Q Hauler Q Indoor <br /> O Q Inactive ® Truck <br /> Longitude - Q Planned ® OTR O End-Use <br /> Container <br /> Business Type(Fill all that apply) <br /> Q New Tire Dealer Q Auto Repair Q Trucking Fleet Q Government Q Retreader Q Dismantler Q Tire Derived Fuel <br /> Q Used Tire Dealer Q Auto Body Q Car Dealer Q Collection Q Crumb Rubber <br /> Q Service Station Q Hauler Q Agriculture Q Shredder ® Other <br /> �-,f t-Yu <br /> Part B - Inspection of Waste Tire Dealer, Generator, Hauler and End-Use Facility ENFORCEMENT STATUS <br /> --- O O <br /> V A HAULING AND MANIFESTREQUIREMENTS <br /> — - - - - Notice Of Violation Extension <br /> Q Q PRC§42951 -Waste Tire Hauler Registration and Transport of Tires <br /> O Q PRC§42953-Contracts with Registered Waste Tire Haulers. Compliance Deadline <br /> O Q PRC§42956-Registration/Decal in Vehicle <br /> Q O 14 CCR§18459-Responsible Entities Complying with Manifesting Requirements Date m / m / m <br /> Q O 14 CCR§18459.1 -Tire Program ID Number from CalRecycle N <br /> O O 114 CCR§18459.2.1 -Submittal of Comprehensive Trip Logs within 90 days (Required for NOV or EXE <br /> N <br /> r <br /> Q Q 14 CCR§18459.3-Retention of Comprehensive Trip Logs for 3 years o <br /> Q O 14 CCR§18460.2-Manifest System Requirements for Registered Waste Tire Haulers Q Referred/CalRecycle Enforcement <br /> f <br /> O O 14 CCR§18461 -Manifest System Requirements for Waste Tire End-Use Facilities W <br /> O O 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators In Compliance-No Violations o <br /> Q_L0 Other:§ <br /> Comments 44 i C /�f1 C.A^da �n!/G�a1l h Jc N <br /> Ie.LC.cC I�'t�y�n� <br /> Inspection Form Included: Q <br /> X2o4 603 3�(3zcc�)��le� —b�Z <br /> Comments Included: ®- - c� �— - <br /> Business�s Signature -Phone Number Inspector's Signature Phone Number_J <br /> INSTRUCTIONS ON BACK Correct:* Incorrect: V (� � E X I A M L�1 1 2 3 62081 <br /> pe a - <br /> White Copy:CalRecycle Yellow Copy:Operator Pink Copy L <br />