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r <br /> Waste Tir` Arvey & Inspection Rei- in Inspection Report Numbt, ■ <br /> CalRecycle State of California m <br /> CalRecycle 181(Rev. (Cal Survey Form - Page 1 I1 �. 17644. 6 <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� � � � � � � Inspection Type(Fill one) <br /> Site Suffix: ` Q Routine Q Re-inspection ® Referral O Observation <br /> Local �+ _ If Referral,choose referral type(Fill one) <br /> Identifier: �C�� V Nk -L Q CHP Q CalRecycle 9 Complaint Q Educational Visit Q Other <br /> Business or Facility Name Inspected By Inspector <br /> ��,�•� � ,,,gyp <br /> Physical Address C� - l l n 6Q bu' <br /> Inspection Date <br /> r <br /> Time In Time Out <br /> Business Rep Title O AM 17;1 O AM <br /> ® PM ID ® PM <br /> Operational Status Tire Type Business Role Storage Type <br /> 7 <br /> Tire Count (Whole/PTE) (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> Active ® Passenger • Generator ®Outdoor <br /> D Q Closed Altered <br /> GPS Latitude Q Hauler Q Indoor <br /> O Q Inactive ® Truck <br /> Longitude - Q Planned OTR O End-Use Q 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 A _&k /� <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 Q PRC§42951 -Waste Tire Hauler Registration and Transport of Tires ®Notice Of Violation Extension <br /> O 0 PRC§42953-Contracts with Registered Waste Tire Haulers. Compliance Deadline <br /> O Q PRC§42956-Registration/Decal in Vehicle <br /> O 0 14 CCR§18459-Responsible Entities Complying with Manifesting Requirements Date J <br /> ® O 14 CCR§18459.1 -Tire Program ID Number from CalRecycle <br /> O O 14 CCR§18459.2.1 -Submittal of Comprehensive Trip Logs within 90 days (Required for NOV or EXE <br /> Q Q 14 CCR§18459.3-Retention of Comprehensive Trip Logs for 3 years o <br /> O O 14 CCR§18460.2-Manifest System Requirements for Registered Waste Tire Haulers Q Referred/CalRecycle Enforcement <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 O In Compliance-No Violations o <br /> Q 1 O 1 Other:§ <br /> Comments <br /> yil <br /> Inspection Form Included: Q -73 <br /> Comments Included: <br /> B siness Rep's Signature Phone Number jnspict4l Sig at re Phone Number <br /> INSTRUCTIONS ON ACK Correct:0 Incorrect: E X P 1 2 3 62081 <br /> ■ White Copy:CalRecycle Yellow Copy:Operator Pink Co y: ® ■ <br />