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Waste Tire SL. vey & Inspection Repon Inspection Report Number ■ <br /> State of California <br /> CalRecycle I 1 - 1242192 <br /> CalRecycle 181(Rev. (Ca[ Survey Form - Page 1 <br /> Dept.of Resources Recycling and Recovery(CalRecycle) <br /> Part A -Survey _ _ _ BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- I �� � _ ` Inspection Type(Fill one) <br /> Site Suffix: 1 ® Routine 0 Re-inspection 0 Referral 0 Observation <br /> Local '-TXV'\ If Referral,choose referral type(Fill one) <br /> Identifier: �^� � �"` �` �2/ 0 CHP 0 CalRecycle 0 Complaint 0 Educational Visit 0 Other <br /> Business or Facility Name / Inspected By Inspector <br /> A 0V <br /> Physical Address cI — L. C) I ���,f� <br /> Inspection Date <br /> Time In Time Out <br /> Business Rep Title <br /> Title AM _ AM <br /> (�� � �. ,i•. l � � I � QPM I I C( J QPM <br /> /Y 1 iL ✓ <br /> Operational Status Tire Type Business Role Storage Type <br /> Tire Count(Whole/PTE) <br /> (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> � � -� L j <br /> ® Active ® Passenger ® Generator 0 Outdoor <br /> O 0 Closed 0 Altered <br /> GPS Latitude 0 Hauler ® Indoor <br /> O 0 Inactive 0 Truck <br /> Longitude — 0 Planned 0 OTR 0 End-Use 0 Container <br /> Business Type(Fill all that apply) <br /> 0 New Tire Dealer 0 Auto Repair 0 Trucking Fleet 0 Government 0 Retreader 0 Dismantler 0 Tire Derived Fuel <br /> 0 Used Tire Dealer 0 Auto Body (a Car Dealer 0 Collection 0 Crumb Rubber <br /> 0 Service Station 0 Hauler 0 Agriculture 0 Shredder 0 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 /> 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 m / m / m <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 EXE 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 /> 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 /> Inspection Form Included: 0 <br /> Comments Included: <br /> p <br /> ss s i ature Phone Number I pet ie <br /> g urPhone Number <br /> INSTRUCTIONS ON BACK Corre Incorrect: E X A M . L 12 3 62081 <br /> ■ White Copy:CalRecycle Yellow Copy:Operator Pink Cop : ® ■ <br />