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Waste Tire Arvey & Inspection Repo# Inspection Report Number <br /> State of California <br /> CalRecycle 11 - 1176592 <br /> CalRecycle 181(Rev. y(Cal Survey Form - Page 1 <br /> • Dept.of Resources Recycling and Recovery(CalRecycle) <br /> part A- Survey BLUE OR BLACK INK PEN <br /> liness Profile Inspection Details <br /> rD- Inspection Type(Fill one) <br /> Site Suffix: 3 C] Z c= c% r 0 Routine 0 Re-inspection 0 Referral 0 Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier: 0 CHP 0 CalRecycle 0 Complaint 0 Educational Visit 0 Other <br /> Business or Facility Name - <br /> �" Inspected By Inspector <br /> Physical Address - l Q / <br /> 3-3? a2 s - <br /> Inspection Date / 2- <br /> S— <br /> Time In Time Out <br /> Business Rep Title 0 AM 0 AM <br /> 0 PM cZ .S 0 PM <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 /> 0 0 Active 0 Passenger 0 Generator 0 Outdoor <br /> O <br /> Latitude ® Closed 0 Altered <br /> GPS - - - - 0 Hauler -O-Indoor- -- - <br /> O 0 Inactive 0 Truck <br /> LongitudeQ Planned 0 OTR End-Use 0- Container <br /> • <br /> Business Type(Fill all that apply) <br /> New Tire Dealer 0 Auto Repair 0 Trucking Fleet 0 Government 0 Retreader 0 Dismantler 0 Tire Derived Fuel <br /> Jsed Tire Dealer 0 Auto Body 0 Car Dealer 0 Collection 0 Crumb Rubber <br /> 0 Service Station 0 Hauler 0 Agriculture 0 Shredder 0 Other <br /> Part B - Inspection of Waste Tire Dealer, Generator, Hauler and End-Use Facility ENFORCEMENT STATUS <br /> V A HAULING AND MANIFEST REQUIREMENTS <br /> — - - - - - - - -- - 0 Notice Of Violation 0 Extension <br /> 0 0 PRC§42951 -Waste Tire Hauler Registration and Transport of Tires <br /> 0 0 PRC§42953-Contracts with Registered Waste Tire Haulers. Compliance Deadline <br /> 0 0 PRC§42956-Registration/Decal in Vehicle <br /> 0 0 14 CCR§18459-Responsible Entities Complying with Manifesting Requirements Date m / m m N <br /> 0 0 14 CCR§18459.1 -Tire Program ID Number from CalRecycle <br /> 0 0 14 CCR§18459.2.1 -Submittal of Comprehensive Trip Logs within 90 days (Required for NOV or EXT) N <br /> 0 0 14 CCR§18459.3-Retention of Comprehensive Trip Logs for 3 years <br /> 0 0 14 CCR§18460.2-Manifest System Requirements for Registered Waste Tire Haulers 0 Referred/CalRecycle Enforcement <br /> f <br /> 0 0 14 CCR§18461 -Manifest System Requirements for Waste Tire End-Use Facilities <br /> Lu <br /> 0 0 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators ®In Compliance-No Violations o <br /> 0 0 Other: - <br /> Comments <br /> C a<td *'7-C.1, 1�7"< <br /> Llection Form Included: 0 <br /> Comments Included: 093-) Ly4-Ir-�6 <br /> Business Rep's Signature Phone Number Inspector's Signature Phone Number <br /> INSTRUCTIONS ON BACK Correct: Incorrec EXAM 11213 62081 <br /> White Copy:CalRecycle Yellow Copy:Operator Pink Copy. <br />