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Waste Tire Ste & Inspection Report Inspection Report Number <br /> CalRecycle State of California Y <br /> CalRecycle 181(Rev. (Cal <br /> Dept.of Resources Recycling and Recovery(CalRecycle) Survey Form - Page 1 I1 1177622 <br /> Part A-Survey BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- Inspection Type(Fill one) <br /> Site Suffix: ` t ® Routine Q Re-inspection Q Referral Q Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier: `�� � t �� �� Q CHP Q CalRecycle Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name C Inspected By Inspector <br /> Physi al A`ddres <br /> Inspection Date <br /> �- - X11 CL fJ�i f <br /> Time In Time Out <br /> Business Rep Title AM O AM <br /> 1 <br /> l I ' L1 �5- 0 PM 0 PM <br /> Operational Status Tire Type Business Role Storage Type <br /> Tire Count (Whole/PTE) n (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> ' ' 1 ® Active Q Passenger ® Generator ® Outdoor <br /> O Q Closed Q Altered <br /> GPS Latitude Q Hauler Q Indoor <br /> O Q Inactive Q Truck <br /> Longitude - Q Planned ® OTR ® 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 Q Hauler Q Agriculture Q Shredder it Other ' L W'�.k yr Z�./_'s <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 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 EXT) 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 0 Referred/CalRecycle Enforcement <br /> Q Q 14 CCR§18461 -Manifest System Requirements for Waste Tire End-Use Facilities w <br /> Q Q 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators ®In Compliance-No Violations <br /> Q 1 Q 1 Other:§ <br /> Comments <br /> Inspection Form Included: Q 9`;209 <br /> Comments Included: ® &JaAk 3.3 -o,2®4 <br /> Business Rep's Signatur Phone Number t S' ture Phone Number <br /> INSTRUCTIONS ON BACK [Correct: Incorrect: x �t 9 E X A M _ E 1 2 3 62081 - <br /> White Copy:CalRecycle Yellow Copy:Operator Pink Co y:L <br />