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Waste Tire S' rey & Inspection Repor Inspection Report Number <br /> State of California <br /> CalRecycle I 1 - 1226567 <br /> CalRecycle 181(Rev. (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 Type(Fill one) <br /> Site Suffix: Z 1 <br /> ® Routine O Re-inspection O Referral O Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier: <br /> - '+vll'� V-\ 1�1,i�W{"�'J 0 CHP Q CalRecycle 0 Complaint Q Educational Visit Q Other <br /> Business or Facility Name J\ Inspected By Inspector <br /> - ' 2v1C'z' �1�E Y I �.lf C <br /> Ad � l _ y /� <br /> Physic dress 3 ` 601-1,27/ N <br /> fZct —- - <br /> �^ Inspection Date <br /> CA `)12-3/ <br /> Time In Time Out <br /> Business Rep 1 Title ® AM ® AM <br /> I�JGtIVL��2. 1 C.�c�lI Q PM Q PM <br /> --- —J-mcr' <br /> 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 ® Generator ® Outdoor <br /> GPS Latitude 0 Closed Q Altered <br /> r-- 1pdoor <br /> 0 Q Inactive ® Truck <br /> Longitude - O Planned Q OTR O End-Use Q Container <br /> Business Type(Fill all that apply) <br /> Q New Tire Dealer Q Auto Repair ® Trucking Fleet Q Government Q Retreader Q Dismantler Q Tire Derived Fuel <br /> Q Used Tire Dealer O 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 /> - - - --- -- - -- --- 0 Notice Of Violation Q Extension <br /> O O PRC§42951 -Waste Tire Hauler Registration and Transport of Tires <br /> O O PRC§42953-Contracts with Registered Waste Tire Haulers. Compliance Deadline <br /> O O PRC§42956-Registration/Decal in Vehicle <br /> O O 14 CCR§18459-Responsible Entities Complying with Manifesting Requirements Date m / m / m <br /> O Q 14 CCR§18459.1 -Tire Program ID Number from CalRecycle a <br /> Q O 14 CCR§18459.2.1 -Submittal of Comprehensive Trip Logs within 90 days (Required for NOV or EXT) N <br /> Q O 14 CCR§18459.3-Retention of Comprehensive Trip Logs for 3 years <br /> O Q 14 CCR§18460.2-Manifest System Requirements for Registered Waste Tire Haulers Q Referred/CalRecycle Enforcement <br /> O Q 14 CCR§18461 - Manifest System Requirements for Waste Tire End-Use Facilities w <br /> 0 Q 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators In Compliance-No Violations <br /> Q Q Other:§ <br /> Comments / <br /> Inspection Form Included: Q <br /> Comments Included: ® - -- -- <br /> Business Rep's Signature Phone Number nspector's Signature Phone Number <br /> INSTRUCTIONS ON BACK Correct:* Incorrect: �( EXAM ILIRI 1112 3 62081 <br /> White Copy:CalRecycle Yellow Copy:Operator Pink Cop <br />