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Waste Tire Avey & Inspection Report , Inspection Report Number <br /> CalRecycle State of California _ <br /> CalRecycle 181(Rev. (Ca[ Survey Form Page 1 I1 1255714 <br /> Dept.of Resources Recycling and Recovery(CalRecycle) <br /> Part A-Survey BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- C I Inspection Type(Fill one) <br /> Site Suffix: 0 Routine Q Re-inspection Q Referral Q Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier: 154 V" (�5U^ Q CHP Q CalRecycle Q Complaint Q Educational Visit Q Other <br /> Business or Facility`Name __ Inspected By Inspector <br /> <)bcV ko V, �(,Vk ���1h <br /> Physical Address' _ <br /> d_vc� t o ^.5263 Inspection Date I l 1 S <br /> "I Time In l Time Out <br /> Business Rep Title ` 1 O AM �' 1 AM <br /> Y <br /> CC.Xe`%v 0_41 �4. vp i�p�Fpl� IPM LJ is 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 /> 0 Active • Passenger * Generator 40 Outdoor <br /> O Q Closed Q Altered <br /> GPS Latitude Q Hauler Q Indoor <br /> O Q Inactive Truck <br /> Longitude - Q Planned OTR Q End-Use Q Container <br /> Business Type(Fill all that apply) <br /> Q New Tire Dealer Q Auto Repair Q Trucking Fleet 0 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 'Or �� -� <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 /> 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 EJ(7) N <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 /> w <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 1 Other:§ <br /> Comments `_� ��5& V,Y.p �� ��1,�h p 1J z-S � <br /> -K 'h C�C7w�� bN� �4 V�� <br /> c. ✓lD \ <br /> �ZC�, ��� pCesLs C5'�' �es`y\ <br /> Inspection Form Included: Qatur <br /> Comments Included: lep's <br /> SiBusiness Rgne Phone Number Inspe or's Signature Phone Number <br /> INSTRUCTIONS ON BACK Correct:18 Incorrect: E X A M P L E 1112 3 62081 <br /> ■ White Copy:CalRecycle Yellow Copy:Operator Pink Copy:LEA © . <br />