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Waste Tire <br /> shy & Inspection Repo�spection Report Number ■ <br /> CalRecycle State of California I 1 - 1176650 <br /> CalRecycle 181(Rev.y(Cal Survey Form - Page 1 <br /> Dept.of Resources Recycling and Recovery(CalRecycle) <br /> Part A- Survey <br /> _ _ BLUE OR BLACK INK-PEN <br /> Business Profile Inspection Details <br /> TPID- Inspection Type(Fill one) <br /> Site Suffix: r 2 3 ® • Routine Q Re-inspection Q Referral Q Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier: 6, Q CHP Q CalRecycle Q Complaint Q Educational Visit Q Other <br /> si <br /> Buness or Facility Name -7 <br /> Inspected By Inspector <br /> /V � <br /> � - <br /> Physical Addr 7 3 ` d <br /> Inspection Date o <br /> Time In Time Out <br /> Business Rep Title O AM O AM <br /> � I ® PM ® PM <br /> Operational Status Tire Type Business Role Storage Type <br /> Tire Count (Whole/PTE) (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> Q Active Q Passenger Q Generator Q Outdoor <br /> O ® Closed Q Altered <br /> GPS Latitude Q Hauler Q Indoor - <br /> O Q Inactive Q Truck <br /> LongitudeQ- Planned Q OTR Q End-Use Q Container <br /> • <br /> Business Type(Fill all that apply) NtA t /r-N N j A <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 ® 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 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 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 EXT) N <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 In Compliance-No Violations <br /> Q Q Other:§ <br /> Comments Q� ... <br /> Inspection Form Included: Q J1i l <br /> Comments Included: 01 -- i��� <br /> Business Rep's Signature Phone Number spector's Signature Phone Number <br /> INSTRUCTIONS ON BACK Correct: Incorrect: IV] E X A P 1 2 3 62081 <br /> White Copy:CalRecycle Yellow Copy:Operator Pink C py: <br />