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Waste Tire 9^y & Inspection Repoftspection Report Number <br /> CalRecycle State of California <br /> Y CalRecycle 181(Rev.y(CalRecycle) Survey <br /> Survey Form - Page 1 11 -1176685 <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 Q Routine ® Re-inspection Q Referral Q Observation <br /> Local �` If Referral,choose referral type(Fill one) <br /> Identifier: JCv1nC w - Q CHP Q CalRecycle Q Complaint-Q Educational Visit Q Other <br /> Business or Facility Name"�C,Yh)cInspected By Inspector <br /> CLt r <br /> t ( crc, � �nec(S 3 �J — ! O / <br /> Physical Address <br /> 130 1 fZT—r av <br /> Inspection Date 1 O <br /> Time In Time Out <br /> Business Rep Title / Q AM Q AM <br /> 11JJ__ __ ® PM � I T � ® 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)O <br /> ® Active ® Passenger ® Generator ® Outdoor <br /> GPS Latitude 0 Q Closed Q Altered Hauler <br /> Q Q Indoor <br /> 0 Q Inactive Q Truck <br /> Longitude - Q End-use Q Container <br /> Q Planned Q OTR <br /> � ------------ ------------- --------- <br /> Business Type(Fill all that apply) <br /> r® New Tire Dealer Q Auto Repair Q Trucking Fleet Q Government Q Retreader Q Dismantler Q Tire Derived Fuel <br /> ® Used Tire Dealer Q 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 /> — - - -- - — --.......... <br /> V A- HAULING AND MANIFESTREQUIREMENTS <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 /> Q Q PRC§42956-Registration/Decal in Vehicle <br /> Q Q 14 CCR§18459-Responsible Entities Complying with Manifesting Requirements Date[:[] <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 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 u, <br /> Q 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 y e205) Le&-e oro <br /> Comments Included: B <br /> Busineeepsnature Phone Number Inspector's Signature Phone Number <br /> INSTRUCTIONS ON BACK LGorrect.0 Incorrect: vN 7PA E X A M L E 1 2 3 62081 <br /> White Copy:CalRecycle Yellow Copy:Operator Pink Cop :L <br />