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Waste Tire Sur vey & Inspection Report Inspection Report Number <br /> Cal Recycle state of California _ <br /> CalRecycle 181(Rev. (Cal Survey Form - Page 1 I1 1210 211 <br /> Dept.of Resources Recycling and Recovery(CalRecycle) <br /> Part A-Survey BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- � 5 3 O � Inspection Type(Fill one) <br /> Site Suffix: �j 0 Routine Q Re-inspection Q Referral Q Observation <br /> Local VN If Referral,choose referral type(Fill one) <br /> Identifier: 50.V1 �d�a V COVE. / Q CHP Q CalRecycle Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name L Inspected By Inspector <br /> Physical Address <br /> 5 I O f A "P c- <br /> S Inspection Date /Time In Time Out <br /> Business Rep Title 0 AM 1 AM <br /> q (3 0 PM 1 0 ` 0 PM <br /> �av1 �ovv.". e,2 Ma�ncr - <br /> Operational Status Tire Type Business Role Storage Type <br /> ' (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> Tire Count(Whole/PTE) � 2 <br /> 40 Active 0 Passenger 0 Generator 0 Outdoor <br /> O Q Closed Q Altered <br /> GPS Latitude Q Hauler Q Indoor <br /> O Q Inactive Q Truck <br /> Longitude — Q End-Use Q Container <br /> Q Planned Q OTR <br /> Business Type(Fill all that apply) <br /> New Tire Dealer S 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 Q 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 /> Q Notice Of Violation Q Extension <br /> Q Q <br /> 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 <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 Exn <br /> Q Q 14 CCR§18459.3-Retention of Comprehensive Trip Logs for 3 years <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 u, <br /> Q Q 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators 40 In Compliance-No Violations o <br /> Q Q Other:§ <br /> Q <br /> Comments ��`�2 [)yC �lV\dl <br /> IC'Y-\ <br /> Inspection Form Included: Q <br /> �°l-ok�Y 209—q6K-'�z8 <br /> Comments Included: �Pho=neNumber <br /> Bu ess Rep' Si Insp tor's Signature Phone Number <br /> INSTRUCTIONS ON BACK Correct: Incorrect: 7X*V E X A M P L E 1 213j 62081 <br /> White Copy:CalRecycle Yellow Copy:Operator Pink Copy:LEA ® ■ <br />