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02 Waste Tire StRe & Inspection Re orL Inspection Report Number <br /> CalRecycle State of California Y <br /> CalRecycle 181(Rev. (Cal <br /> Dept.of Resources Recycling and Recovery(CalRecycle) Survey Form - Page 1 11 - 1177735 <br /> Part A-Survey BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- Inspection Type(Fill one) <br /> Site Suffix: I LI O a j ® Routine Q Re-inspection Q Referral Q Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier: , �� G �1 Q CHP Q CalRecycle Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name ( Inspected By Inspector <br /> IUfl. f_C�,` IiX>� E )ptlr-n,�- nf�t <br /> Physical Address - l ��1••(,Jl�; i1 <br /> Inspection Date <br /> �uP,kC� ttt 153�� <br /> Time In Time Out <br /> Business Rep Title O AM O AM <br /> l� PM � fl (� ®PM <br /> �.1111C� z1 V �cmvr7.✓ �rc�t'u- �L <br /> Operational Status Tire Type Business Role Storage Type <br /> Tire Count(Whole/PTE) (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> Q Active ® Passenger ® Generator ® Outdoor <br /> Q Closed Q Altered <br /> GPS Latitude Q Hauler Q Indoor <br /> 0 Q Inactive ® Truck <br /> Longitude - Q Planned Q OTR Q End-Use 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 i® Other F &enfi-5. <br /> Part B - Inspection of Waste Tire Dealer, Generator, Hauler and End-Use Facility ENFORCEMENT STATUS <br /> V A HAULING AND MANIFEST REQUIREMENTS <br /> Q Notice Of Violation Q Extension <br /> Q Q PRC§42951 -Waste Tire Hauler Registration and Transport of Tires <br /> Q Q PRC§42953-Contracts with Registered Waste Tire Haulers. Compliance Deadline <br /> PRC§42956-Registration/Decal in Vehicle <br /> Q Q 14 CCR§18459-Responsible Entities Complying with Manifesting Requirements Date M / m / m <br /> Q Q 14 CCR§18459.1 -Tire Program ID Number from CalRecycle <br /> Q Q 14 CCR§18459.2.1 -Submittal of Comprehensive Trip Logs within 90 days (Required for NOV or EXE N <br /> Q Q 14 CCR§18459.3-Retention of Comprehensive Trip Logs for 3 years <br /> 0 <br /> Q Q 14 CCR§18460.2-Manifest System Requirements for Registered Waste Tire Haulers Q Referred/CalRecycle Enforcement <br /> Q Q 14 CCR§18461 -Manifest System Requirements for Waste Tire End-Use Facilities w <br /> Q Q 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators ®In Compliance-No Violations o <br /> Q Q Other:§ <br /> Comments <br /> comm .nf� <br /> Inspection Form Included: <br /> Comments Included: WBineiZep's <br /> 'P'G 7Signature Phone Number I pec s gn9ture Phone Number <br /> INSTRUCTIONS O BACK Correct: Incorrect: E X A P 1 2 3 62081 <br /> White Copy:CalRecycle Yellow Copy:Operator Pink CoVL <br />