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Waste Tire Survey & Inspection Report Inspection Report Number ■ <br /> CalRecycle State of California <br /> CalRecycle 181(Rev. (Ca[ Survey Form - Page 1 I1 r :1.176833 <br /> Dept.of Resources Recycling and Recovery(CalRecycle) Ell n in BLUE OR BLACK INK PEN <br /> Part A-Survey <br /> Business Profile Inspect ail <br /> TPID- l ] Inspection Type(Fill one) <br /> Site Suffix: ' �i ``� © l ® Routine Q Re-inspection Q Referral Q Observation <br /> LocalIf Referral,choose referral type(Fill one) <br /> Q CHP Q CalRecycle Q Complaint Q Educational Visit Q Other <br /> Identifier: `�Crac N <br /> Business or Facility Name Inspected By Inspector <br /> Physical Address <br /> A, ALY1 <br /> Inspection Date <br /> r <br /> / 6 <br /> � } ,1 l l l <br /> v _l tO Time In Time Out <br /> 4V AM `0 AM <br /> Business Rep Title ) <br /> C? 0 P l 0 C3 QPM <br /> L r1L l T �✓ _ C./ - - --- — 4' 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 (Whole/PTE) r 0 Active ® Passenger ® Generator Q Outdoor <br /> Q Closed Q Altered <br /> GPS Latitude Q Hauler ® Indoor <br /> Q Inactive Q Truck <br /> Longitude - Q Planned Q OTR Q End-Use Q Container <br /> Business Type(Fill all that apply) <br /> $ 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 Q Other <br /> Part B- Inspection of Waste Tire Dealer, Generator, Hauler and End-Use Facility ENFORCEMENT STATUS <br /> V A HAULING AND MANIFEST REQUIREMENTS 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 /> QQ 14 CCR§18459-Responsible Entities Complying with Manifesting Requirements Date m m N <br /> Q Q 14 CCR§18459.1 -Tire Program ID Number from CalRecycle <br /> (Required for NOV or EXT N <br /> Q Q 14 CCR§18459.2.1 -Submittal of Comprehensive Trip Logs within 90 days <br /> Q Q 14 CCR§18459.3-Retention of Comprehensive Trip Logs for 3 years <br /> Q IQ 14 CCR§18460.2-Manifest System Requirements for Registered Waste Tire Haulers Q Referred/CalRecycle EnforcementLu <br /> Lu <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 Other:§ -- - <br /> Comments <br /> Inspection Form Included: Q <br /> -4'66 <br /> Comments Included: Busines Rep's Signature Phone Number n r' nature Phone Number <br /> 62081 <br /> INSTRUCTIONS ON BACK Correct:6 Incorrect: ® � E X A P L 1 2 3 <br /> ■ ■ <br /> White Copy:CalRecycle Yellow Copy:Operator Pink Cop :L <br />