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Waste Tire Ste & Inspection Re ort Inspection Report Number <br /> CalRecycle State of California Y <br /> Y CalRecycle 181(Rev. (Cal <br /> Dept.of Resources Recycling and Recovery(CalRecycle) Survey Form - Page 1 I1 - 1245319 <br /> Part A-Survey BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- � � Q� ,2, � (� `„ _ Q I Inspection Type(Fill one) <br /> Site Suffix: `' �l _ ( l1 e Routine Q Re-inspection Q Referral Q Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier: r) Uig C Q CHP Q CalRecycle Q Complaint Q Educational Visit Q Other <br /> Business or Facility CsName Inspected By Inspector� <br /> Physicals <br /> Inspection Date <br /> Business Rep Title Time In% — O AM Time Out AM <br /> L� -5 ®PM 3 V 0 PM <br /> Operational Status Tire Type Business Role Storage Type <br /> Tire Count ho /PTE) / (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> Il . Active a Passenger' 0 Generator Q Outdoor <br /> O Q Closed Q Altered <br /> GPS Latitude Q Hauler Q Indoor <br /> O Q Inactive Q Truck <br /> Longitude - Q Planned Q OTR Q End-Use 0 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 /> 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 <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 /> 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 EXE <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 W <br /> Q Q 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators <br /> g)In Compliance-No Violations o <br /> Q 1 Q Other:§ ll <br /> Comments <br /> Inspection Form Included: O/k4g <br /> A, <br /> Comments Included: ( <br /> Business Rep's Signature Phone Number ns ctor's Si Phone Number <br /> INSTRUCTIONS ON BACK C7X7*=qf]jEjX�AjMjPjLjEjorrect:0 Incorrect: 1112 3 62081 <br /> ■ White Copy:CalRecycle Yellow Copy:Operator Pink Copy:LEA © ■ <br />