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03 Waste Tire Sley & Inspection ReporLelnspection Report Number <br /> CalRecycle State of California 11 - 1255946 <br /> ry <br /> CalRecycle 181(Rev. (Ca[ Survey Form - Page 1 <br /> Dept.of Resources Recycling and Recove (CalRecycle) <br /> Part A-Survey_ _ BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details y, <br /> TPID- Inspection Type(Fill one) <br /> Site Suffix: I S C, 0 Routine Q Re-inspection Q Referral Q Observation <br /> Local e If Referral,choose referral type(Fill one) <br /> Identifier: COy� `7 Q CHP Q CalRecycle Q Complaint Q Educational Visit Q Other <br /> 4"_ A <br /> Business or Facility Name \ Inspected By Inspector <br /> Physical Address <br /> V C 0r - <br /> �S2`ta -- <br /> Inspection Date <br /> L� <br /> Time In Time Out <br /> Business Rep Title 0 AM 0 AM <br /> PM 1 ® a 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 /> e Active Q Passenger 0 Generator Q Outdoor <br /> O Q Closed Q Altered <br /> ��� Latitude Q Hauler � Indoor <br /> O Q Inactive 0 Truck <br /> Longitude – Q Planned 9 OTR Q End-Use Q Container <br /> Business Type(Fill all that apply) ' &r <br /> Q New Tire Dealer Q Auto Repair Q Trucking Fleet Q Government Q Retreader 0 Dismantler Q Tire Derived Fuel, <br /> r, <br /> r: <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 <br /> 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 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 <br /> a <br /> Q Q 14 CCR§18459.3-Retention of Comprehensive Trip Logs for 3 years <br /> Q Q 14 CCR§18460.2-Manifest System Requirements for Registered Waste Tire Haulers Q Referred/CalRecycle Enforcement <br /> Lu <br /> Q Q 14 CCR§18461 -Manifest System Requirements for Waste Tire End-Use Facilities <br /> Q Q 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators In compliance-No Violations o <br /> Q Q Other:§ <br /> Comments V �'h M+� �-�J �f _—1 M<<i �Tl®� V\ dv\. <br /> Inspection Form Included: (� <br /> Comments Included: <br /> iness Rep's I re Phone Number Phone Number <br /> Inspe or's Signature <br /> INSTRUCTIONS ON BACK Correct:0 Incorrect: vx 7 EXAMPLE 1 2 3 62081 <br /> White Copy:CalRecycle Yellow Copy:Operator Pink Copy:LEA ® ■ <br />