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a;h`�+d�a�::o�'--::-a.� ��':�x�:�_ssi*_:`_fie �7 i � - - - •.no.as_-.--sk�a1.�a�-��v�.P..-asa-we�ti�r:;sm,onc;,�ti_c,::a. :.::� <br /> Waste Tireurvey & Inspection Report Inspection Report Number ■ <br /> cle State of California <br /> CalRecycle CalRecycle 181(Rev.y(Cal Survey Form - Page 1 I 1 1245161 <br /> Dept.of Resources Recycling and Recovery(CalRecycle) <br /> Part A-Survey BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- � ® a � � � (fir � � J Inspection Type(Fill one) <br /> Site Suffix. / / S Routine Q Re-inspection Q Referral Q Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier: 11 JO w y Q CHP Q CalRecycle Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name Inspected By Inspector <br /> �U ,, a . a 16u _c, ' <br /> Physical Address ✓ - ( �� I //]IV( vt � �i 1`- �'' <br /> Inspection Date j (;I 2- 1 <br /> Time In Time Out <br /> Business Rep Title z 0 AM 0 AM <br /> I J PM S S PM <br /> Operational Status Tire Type Business Role Storage Type <br /> (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> Tire Count 04/PTE) <br /> ® Active ® Passenger ® Generator 0 Outdoor <br /> O Q Closed • Altered <br /> GPS Latitude ® Hauler Q Indoor <br /> o Q Inactive A 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 Q 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 0 Hauler Q Agriculture Q Shredder Q Other <br /> Part B- Inspection of Waste Tire Dealer, Generator, Hauler and End-Use Facility ENFORCEMENT STATUS <br /> V I A I 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 /> 10 0 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 /> a <br /> N <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 /> f <br /> Q Q 14 CCR§18461 -Manifest System Requirements for Waste Tire End-Use Facilities W <br /> Q O 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators In Compliance-No Violations o <br /> Q Q Other:§ <br /> Comments <br /> 0 <br /> Inspection Form Included: Q (� <br /> Comments Included: ` I �- �D <br /> Busine ure Phone Number Inspector's Signature Phone Number <br /> INSTRUCTIONS ON BACK Correct:* Incorrect: X lii�) q �jEjXjAjMjPjLjEj 11.. 2 3 62081 <br /> ■ White Copy:CalRecycle Yellow Copy:Operator Pink Copy:LEA © ■ <br />