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Waste Tire Sui dey & Inspection Report Inspection Report Number <br /> CalRecycle State of California( I 1 - 1196561 <br /> CalRecycle 181(Rev. y(Cal Survey Form - Page 1 <br /> Dept.of Resources Recycling and Recovery(CalRecycle) <br /> Part A-Survey BLUE OR BLACK INK PEN_ <br /> Business Profile Inspection Details <br /> TPID- Inspection I , Inspection Type(Fill one) <br /> Site Suffix: -1 U 0 Routine Q Re-inspection Q Referral Q Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier: �&-Y\"5,0ry n l\.;-\Y,\ �,n C� Q CHP Q CalRecycle Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name "`� Inspected By Inspector <br /> Physical Address <br /> �v12 �2ok� �c1�• <br /> Inspection Date 1 / O <br /> Time In Time Out <br /> Business Rep Title 1 O AM O AM <br /> PM PM <br /> `a�n� �a e� <br /> - -- Operational Status Tire Type Business Role Storage Type <br /> Tire Count(Whole/PTE) /J� (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> le IS Active Q Passenger 0 Generator Q Outdoor <br /> D <br /> GPS Latitude Q Closed Q Altered Q Hauler Q Inddddddoor� <br /> o Q Inactive Q Truck <br /> Longitude - Q Planned 0 OTR Q End-Use Q Container <br /> Business Type(Fill all that apply) oOAAC <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 /> Q Service Station Q Hauler Q Agriculture Q Shredder 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 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 O 14 CCR§18459-Responsible Entities Complying with Manifesting Requirements Date m / m / 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 EX7) <br /> Q O 14 CCR§18459.3-Retention of Comprehensive Trip Logs for 3 years o <br /> Q O 14 CCR§18460.2-Manifest System Requirements for Registered Waste Tire Haulers Q Referred/CalRecycle Enforcement <br /> 2 <br /> Q O 14 CCR§18461 -Manifest System Requirements for Waste Tire End-Use Facilities W <br /> Q O 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators •In Compliance-No Violations o <br /> Q Q Other:§ <br /> Comments QAC. -� ov, <br /> ` <br /> C' N% — <br /> Inspection Form Included: Q /' ` i 41 <br /> -0 t `O <br /> Comments Included: 1 <br /> Busine s Rep's gnature Ph a umber Inspect is Signature Phone Number <br /> INSTRUCTIONS ON BACK Cor ect:0 Incorrect: g EXAMPLE 1112 3 62081 <br /> ■ White Copy:CalRecycle Yellow Copy:Operator Pink Copy:LEA ® ■ <br />