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Waste Tire Sftey & Inspection Repo-, Inspection Report Number <br /> CalRecycle State of California — <br /> CalRecycle 181(Rev.y(CalRecycle) Survey <br /> Survey Form - Page 1 I 1 1. 255859 <br /> Dept.of Resources Recycling and Recovery(CalRecycle) <br /> Part A- Survey BLUE OR BLACK INK PEN <br /> Business Profile 'Inspection Details —� <br /> TPID- ' " _ O Inspection Type(Fill one) <br /> Site Suffix: (Z(� ` 0 Routine Q Re-inspection Q Referral Q Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier. �kh �V� 0-,n Ca V0CHP � CalRAYcle 0 Complaint 0 Educational Visit 0 Other <br /> Business or Facility Name - - - - <br /> Inspected By Inspector <br /> 1� <br /> T22�( S �C,-c 0 _ ` O <br /> Physical Atldress 6 �/1 A T� Q <br /> 1,1,octo P�1e;►12 C� . " <br /> LInspection Date o U/ -2 / <br /> Time In Time Out <br /> Business Rep .{ Title C 0 AM I 1 Q AM <br /> QPM l � I O OPM <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 <br /> Q Active O Passenger I Q Generator Q Outdoor <br /> O Closed Q AltAl`A N � <br /> l <br /> GPS Latitude O Hauler O Indoor <br /> O Q Inactive Q Truck <br /> Longitude - Q Planned Q OTR O End-Use Q Container <br /> Business Type(Fill all that apply) <br /> I <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 /> O Service Station ! Hauler Q Agriculture Q Shredder Other <br /> Part B- Inspection of Waste Tire Dealer, Generator, Hauler and End-Use Facility rONotice <br /> FORCEMENT STATUS <br /> V I A HAULING AND MANIFEST REQUIREMENTS <br /> - - - Of Violation Q Extension <br /> O O PRC§42951 -Waste Tire Hauler Registration and Transport of Tires <br /> O O PRC§42953-Contracts with Registered Waste Tire Haulers. Compliance Deadline <br /> Q O PRC§42956-Registration/Decal in Vehicle <br /> O O 14 CCR§18459-Responsible Entities Complying with Manifesting Requirements Date <br /> O O 14 CCR§18459.1 -Tire Program ID Number from CalRecycle K <br /> O O 14 CCR§18459.2.1 -Submittal of Comprehensive Trip Logs within 90 days (Required for NOV or EXT) <br /> O Q 14 CCR§18459.3-Retention of Comprehensive Trip Logs for 3 years o <br /> O Q 14 CCR§18460.2-Manifest System Requirements for Registered Waste Tire Haulers Q Referred/CalRecycle Enforcement 4 <br /> O O 14 CCR§18461 -Manifest System Requirements for Waste Tire End-Use Facilities to <br /> O O 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators <br /> In Compliance-No Violations - <br /> C) O Other:§ <br /> Comments�-N.? 'l+e &- C- C> C,1 `i�t Q <br /> me) V,OIWC\Ows <br /> o- vSzS--T:PD I92)z69_ <br /> 12 ecow�w,er.� `Cez 1 SIN SV -o\ 6--- closed . - <br /> Inspection Form Included: <br /> Comments Included: (�'� �/(J� ��i����'(iwJ <br /> usin s ep' one NumberInspec ors Signature Phone Number <br /> - - 62081 <br /> INSTRUCTIONS O B K Correct: Incorrect: ' + � E X A M�P L E 1 2 3 <br /> hite op le Yellow Copy:Operator Pink Copy:LEA <br />