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Waste Tire Alvey & Inspection Reporpinspection Report Number. <br />CalRecycle State of California I 1- 1245240 <br />CalRecycle 181 (Rev. (Cal Survey Form - Page 1 <br />Dept. of Resources Recycling and Recovery(CalRecycle) <br />part A - S,uvPv BLUE OR BLACK INK PEN <br />Business Profile <br />Inspection Details <br />TPID - <br />Site Suffix: " _I z <br />$fFpiin Type (Fill one) <br />EXAMPLE 1 2 3 <br />ne 0 Re -inspection Q Referral Q Observation <br />If Referral, choose referral type (Fill one) <br />Visit Q Other <br />Local � <br />Identifier: J <br />V� r vy� <br />Q CHP Q CalRecycle Q Complaint Q Educational <br />Business or Facility Name <br />Inspected By Inspector <br />t <br />20v, kl2; <br />Physical Address <br />04` 'F. Or <br />S 6--v �� ���� <br />Inspection Date <br />G, <br />Time In Time Out <br />Business Rep TitleAM <br />2,�% �'`� O AM <br />� O 00'PM ` V 49 PM <br />aCt <br />Operational Status <br />Tire Type <br />Business Role <br />Storage Type <br />Tire Count (Whole/PTE) �''\ <br />v O <br />(Fill one only) <br />Active <br />Q Closed <br />(Fill all that apply) <br />49 Passenger <br />Q Altered <br />(Fill all that apply) <br />0 Generator <br />Q Hauler <br />(Fill all that apply) <br />Outdoor <br />Q Indoor <br />O <br />GPS Latitude <br />O <br />Q Inactive <br />Q Truck <br />Longitude - <br />Q Planned <br />Q OTR <br />Q End -Use <br />Q Container <br />Business Type (Fill all that apply) <br />O New Tire Dealer Q Auto Repair Q Trucking Fleet Q Government Q Retreader Q Dismantler Q Tire Derived Fuel <br />4 Used Tire Dealer Q Auto Body Q Car Dealer Q Collection Q Crumb Rubber <br />Q Service Station Q Hauler Q Agriculture Q Shredder Q Other <br />Part <br />B - <br />Inspection of Waste Tire Dealer, Generator, Hauler and End -Use Facility <br />ENFORCEMENT STATUS <br />V <br />A <br />HAULING AND MANIFEST REQUIREMENTS <br />®Notice Of Violation Q Extension <br />Q <br />Q <br />PRC § 42951 - Waste Tire Hauler Registration and Transport of Tires <br />Q <br />Q <br />PRC § 42953 - Contracts with Registered Waste Tire Haulers. <br />Compliance Deadline <br />Q <br />O <br />PRC § 42956 - Registration/Decal in Vehicle <br />14 CCR § 18459 - Responsible Entities Complying with Manifesting Requirements <br />Dater) <br />Q <br />14 CCR § 18459.1 - Tire Program ID Number from CalRecycle <br />r�►� <br />Q <br />Q <br />14 CCR § 18459.2.1 - Submittal of Comprehensive Trip Logs within 90 days <br />(Required for NOV or EX7) <br />Q <br />Q <br />14 CCR § 18459.3 - Retention of Comprehensive Trip Logs for 3 years <br />Q <br />Q <br />14 CCR § 18460.2 - Manifest System Requirements for Registered Waste Tire Haulers <br />Q Referred / CalRecycle Enforcement <br />Q <br />Q <br />14 CCR § 18461 - Manifest System Requirements for Waste Tire End -Use Facilities <br />Q <br />Q <br />14 CCR § 18462 - Manifest System Requirements for Tire Dealers or Waste Tire Generators <br />Q In Compliance - No Violations <br />Q <br />Q <br />Other: § <br />Comments <br />` <br />rrjStt•- eCk�6l(-\ <br />-'4CS <br />Inspection Form Included: Q <br />'l <br />41nspctor's <br />Comments Included: ® <br />Business Rep's Signature Phone Number Signature Phone Number <br />R <br />INSTRUCTIONS ON BACK <br />Correct: 4D <br />Incorrect: � W <br />EXAMPLE 1 2 3 <br />62081 <br />■ <br />White Copy: CalRecycle <br />Yellow Copy: Operator <br />Pink Copy: LEA <br />R <br />