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Waste Tire Su, rey & Inspection Repor0blnspection Report Number <br /> State of California <br /> CalRecycle I 1 - 1242147 <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- ' � � � h V � - � � Inspection Type(Fill one) <br /> Site Suffix: y 0 Routine Q Re-inspection Q Referral Q Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier: �QVZ Q CHP Q CalRecycle Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name Inspected By Inspector <br /> Physical Address <br /> Inspection Date d q / -2 / <br /> Time In Time Out <br /> Bushiness Rep �` Title O AM 2 /' O AM <br /> _ &' 7Cp 1 r 0 PM ? 40 PM <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 /> 06 Active I Q Passenger • Generator <br /> Q Outdoor <br /> O Q Closed Q Altered +U/A <br /> GPS Latitude Q Hauler Q Indoor <br /> O Q Inactrve I Q Truck <br /> Longitude - Q Planrod OTR Q End-Use Q Container <br /> Business Type(Fill all that apply) <br /> Q New Tire Dealer Q Auto Repair Q Trucking Fleet Q Government Q Flom 62 r 0 Dismantler Q Tire Derived Fuel <br /> Q Used Tire Dealer Q Auto Body Q Car Dealer Q Collection Q C onb Rimer <br /> Q Service Station Q Hauler Q Agriculture Q Shredder is Olfim <br /> Part B - Inspection of Waste Tire Dealer, Generator, Hauler and End-Use Facr7Ry ENFORCEMENT STATUS <br /> V A HAULING AND MANIFEST REQUIREMENTS <br /> -i Q Notice Of Violation Q Extension <br /> Q Q PRC§42951 -Waste Tire Hauler Registration and Transport of Tires <br /> I <br /> Q Q PRC§42953-Contracts with Registered Waste Tire Haulers. Compliance Deadline <br /> Q Q PRC§42956-Registration/Decal in Vehicle <br /> Q Q 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 EXE N <br /> Q Q 14 CCR§18459.3-Retention of Comprehensive Trip Logs for 3 years o <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 W <br /> Q Q 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators •In Compliance-No Violations o <br /> Q 1 Q 1 Other:§ <br /> Comments 4�.a�'`a"� �CiS� ��''L- �v�.SE}eC.•taC)� C`�j1nP, 01n -1�n�S_��4C C�,YL� �, <br /> l�O U o O <br /> Inspection Form Included: -23 7 _ <br /> Comments Included: / <br /> s e p g tur one Numb6r Inspec is Signature Phone Number <br /> INSTRUCTIONS ON BA rrect: Incorrect: E X A M P L E 1 2 3 62081 <br /> White Copy:CalRecycle Yellow Copy:Operator Pink Copy:LEA <br />