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Waste Tire Su, Jey & Inspection Report Inspection Report Number <br /> CalRecycle State of California I 1 - 1177528 <br /> CalRecycle 181(Rev. (CalRecycle) <br /> Survey Form - Page 1 <br /> Dept.of Resources Recycling and Recovery(CalRecycle) <br /> Part A -Survey BLUE OR BLACK INK PEN <br /> 'siness Profile Inspection Details <br /> Ip_ 0 I Inspection Type(Fill one) <br /> Site Suffix: Is Routine 0 Re-inspection 0 Referral 0 Observation <br /> Local I ]. If Referral,choose referral type(Fill one) <br /> Identifier: �G( � JO(,(,G1 lA 1 n Cou 0 CHP 0 CalRecycle 0 Complaint 0 Educational Visit 0 Other <br /> Business or Facility Name I _Ij <br /> Inspected By Inspector <br /> 1 <br /> be si n i nj <br /> Physical Addre s <br /> q o� r) <br /> G4 ri J')q o Inspection Date <br /> Time In Time Out <br /> Business Rep Title O AM (� O AM <br /> moi- n i : ' s ® PM -1 0 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 0 Passenger ® Generator 0 Outdoor <br /> O 0 Closed 0 Altered NIA <br /> GPS Latitude 0 Hauler 0 Indoor <br /> o ® Inactive 0 Truck <br /> Longitude - 0 Planned ® OTR 0 End-Use 0 Container <br /> Business Type(Fill all that apply) cr� <br /> (� New Tire Dealer 0 Auto Repair 0 Trucking Fleet 0 Government 0 Retreader 0 Dismantler 0 Tire Derived Fuel <br /> Used Tire Dealer 0 Auto Body 0 Car Dealer 0 Collection 0 Crumb Rubber <br /> 0 Service Station 0 Hauler 0 Agriculture 0 Shredder 0 Other 1poti Low <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 0 Extension <br /> 0 0 <br /> PRC§42951 -Waste Tire Hauler Registration and Transport of Tires <br /> 0 0 PRC§42953-Contracts with Registered Waste Tire Haulers. Compliance Deadline <br /> PRC§42956-Registration/Decal in Vehicle <br /> 0 0 14 CCR§18459-Responsible Entities Complying with Manifesting Requirements Date <br /> 0 0 14 CCR§18459.1 -Tire Program ID Number from CalRecycle <br /> 0 0 14 CCR§18459.2.1 -Submittal of Comprehensive Trip Logs within 90 days (Required for NOV or EX7) N <br /> 0 0 14 CCR§18459.3-Retention of Comprehensive Trip Logs for 3 years o <br /> 0 0 14 CCR§18460.2-Manifest System Requirements for Registered Waste Tire Haulers 0 Referred/CalRecycle Enforcement <br /> Uj <br /> 0 0 14 CCR§18461 -Manifest System Requirements for Waste Tire End-Use Facilities W <br /> 0 0 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators In Compliance-No Violations o <br /> 0 0 Other:§ <br /> Comments <br /> U <br /> ,pection Form Included: 0 <br /> Comments Included: — $ <br /> 4E3signess—Rep's Signature Phone Number 1 lnsp or's Signature Phone Number <br /> INSTRUCTIONS ON BACK Correct:0 Incorrect: EXAM L E J112 3 62081 <br /> White Copy:CalRecycle Yellow Copy:Operator Pink Co y: <br />