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Waste Tire Sui Bey & Inspection Report Inspection Report Number ■ <br /> cle State of California <br /> Cal Rec — <br /> Y CalRecycle 181(Rev. (Cal <br /> Survey Form - Page 1 I1 12 4 2 2 7 6 <br /> Dept.of Resources Recycling and Recovery Recycle) <br /> Part A- Survey_ BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- 1 O � Inspection Type(Fill one) <br /> Site Suffix: Routine 0 Re-inspection 0 Referral 0 Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier: � �h / 0 CHP 0 CalRecycle 0 Complaint 0 Educational Visit 0 Other <br /> Business or Facility NameInspected By Inspector <br /> Physical Address <br /> 21200 eaco�-:5�. '�• <br /> Inspection Date <br /> Time In Time Out <br /> Business R p TitlePI Q O AM O AM <br /> ('r � � �- 0 PM O PM�U plc 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 /> –, ! Active * Passenger 0 Generator 0 Outdoor <br /> O 0 Closed 0 Altered <br /> GPS Latitude 0 Hauler 0 Indoor <br /> O 0 Inactive Truck <br /> Longitude – 0 Planned OTR 0 End-Use 0 Container <br /> Business Type(Fill all that apply) <br /> 0 New Tire Dealer 0 Auto Repair 0 Trucking Fleet 0 Government 0 Retreader 0 Dismantler 0 Tire Derived Fuel <br /> 0 Used 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 -TVan\>ec * CA.q-pQ�' <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 /> O O <br /> 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 <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 EXE N <br /> 0 0 14 CCR§18459.3-Retention of Comprehensive Trip Logs for 3 years <br /> 0 <br /> 0 0 14 CCR§18460.2-Manifest System Requirements for Registered Waste Tire Haulers 0 Referred/CalRecycle Enforcement <br /> 0 0 14 CCR§18461 -Manifest System Requirements for Waste Tire End-Use Facilities u, <br /> 0 0 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators •In Compliance-No Violations o <br /> 0 1 O Other:§ <br /> Comments N;�&—_ <br /> c 'r— <br /> Inspection Form Included: <br /> Comments Included: � �- Signature Number Rep' Signature Ins�pP�ho�ne�Nu <br /> mbelr <br /> 62081�INSTRUCTIONS ON BACK Correct:0 Incorrect: W N( E X A M <br /> PI L E 1 2 3 <br /> ■ White Copy:CalRecycle Yellow Copy:Operator Pink Copy:LEA ® ■ <br />