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0 Waste Tire S&ey & Inspection ReporAnspection Report Number <br />Cal Recycle State of California I 1 - 1255815 <br />CalRecycle 181 (Rev. y (CalRecycle)Survey <br />Survey Form - Page 1- <br />Dept. of Resources Recycling and Recovery (CalRecycle) <br />Part A - Ciirvcv BLUE OR BLACK INK PEN <br />Business Profile <br />Q <br />Inspection Details <br />Q <br />TPID -Q <br />Site Suffix: coV <br />PRC § 42953 - Contracts with Registered Waste Tire Haulers. <br />Q <br />Inspection Type (Fill one) <br />PRC § 42956 - Registration/Decal in Vehicle <br />Q <br />Q <br />14 CCR § 18459 - Responsible Entities Complying with Manifesting Requirements <br />0 Routine Q Re -inspection Q Referral Q Observation <br />Referral, choose referral type (Fill one) <br />Q Other <br />LocalIf <br />Identifier: in C t <br />14 CCR § 18459.1 - Tire Program ID Number from CalRecycle <br />V ( <br />Q CHP Q CalRecycle Q Complaint Q Educational <br />Visit <br />Business or Facility Name <br />Inspected By Inspector <br />Q <br />I r a i v vcAL <br />Address <br />-' l <br />Q <br />Physical <br />14 CCR § 18461 - Manifest System Requirements for Waste Tire End -Use Facilities <br />/ �' ��v,/� <br />/ e hiy �-� 1 <br />n,`�v <br />-' <br />)—t42— w y ate- � �n <br />VjAa 1�1 CC, <br />�' 7: 5-7�> 3 <br />Inspection Date <br />Time In Time Out <br />Business Rep <br />Title <br />O AM 7 / , O AM <br />(� G ® PM v ' �V ® PM <br />OL I <br />Operational Status <br />Tire Type <br />Business Role <br />Storage Type <br />Tire Count (Whole/PTE) <br />(Fill one only) <br />(Fill all that apply) <br />(Fill all that apply) <br />(Fill all that apply) <br />® Active <br />Q Closed <br />Q Passenger <br />Q Altered <br />0 Generator <br />Q Hauler <br />a Outdoor <br />Q Indoor <br />O <br />GPS Latitude <br />O <br />Q Inactive <br />0 Truck <br />Longitude - <br />Q Planned <br />Q OTR <br />Q End -Use <br />Q Container <br />Business Type (Fill all that apply) <br />Q New Tire Dealer Q Auto Repair <br />Q Trucking Fleet Q Government Q Retreader Q Dismantler Q Tire Derived Fuel <br />Q Used Tire Dealer Q Auto Body <br />Q Car Dealer Q Collection Q Crumb Rubber <br />Q Service Station Q Hauler <br />Q Agriculture Q Shredder 0 Other Tvus� <br />Part B - Inspection of Waste Tire Dealer, Generator, Hauler and End -Use Facility <br />V F A-1 HAULING AND MANIFEST REQUIREMENTS <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 />Q <br />Q <br />PRC § 42956 - Registration/Decal in Vehicle <br />Q <br />Q <br />14 CCR § 18459 - Responsible Entities Complying with Manifesting Requirements <br />Q <br />Q <br />14 CCR § 18459.1 - Tire Program ID Number from CalRecycle <br />Q <br />Q <br />14 CCR § 18459.2.1 - Submittal of Comprehensive Trip Logs within 90 days <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 <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 />Other: § <br />Comments <br />rete a n -d 4�u 6 l l r -w, �s <br />ENFORCEMENT STATUS <br />Q Notice Of Violation Q Extension <br />Compliance Deadline <br />Datem/m/m <br />(Required for NOV or EX7) <br />Q Referred / CalRecycle Enforcement <br />® In Compliance - No Violations <br />Inspection Form Included: Q <br />Comments Included: ® — <br />Business Rep's Signature Phone Number Inspecto�&gna�ture hone Number <br />INSTRUCTIONS ON BACK Correct: Incorrect: W 62081 <br />E X A M L 1 2 3 <br />White Copy: CalRecycle Yellow Copy: Operator Pink Copy: <br />0 <br />f <br />Lu <br />