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Waste Tire S,.. vey & Inspection Repor, Inspection Report Number <br /> State of California <br /> CalRecycle I 1 - 1226357 <br /> CalRecycle 181(Rev. (Cal 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- Inspection Type(Fill one) <br /> Site Suffix: I ,(..� © - b L 0 Routine Q Re-inspection Q Referral Q Observation <br /> Local j If Referral,choose referral type(Fill one) <br /> Identifier: �a� �c^ct �� �QIV�vt., Q CHP Q CalRecycle Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name VV Inspected By Inspector <br /> ,� "rAC� � <br /> Physical ress - 1 0 1 14, ,In 10(.1C <br /> 441-1l (Jc..L"l <br /> Inspection Date r ? ? <br /> Time In Time Out <br /> Business Rep i Title 6' <br /> I*AM /! �l �AM <br /> &I �1 \YYIL"i Vt I �LC✓l I t 2 F3O PM � 1 � `7 C./ O 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 /> ® Active ® Passenger ® Generator 0 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 0 End-Use Q Container <br /> Business Type(Fill all that apply) <br /> Q New Tire Dealer ® Auto Repair Q Trucking Fleet Q Government Q Retreader Q Dismantler Q Tire Derived Fuel <br /> Q Used Tire Dealer 0 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 Q PRC§42951 -Waste Tire Hauler Registration and Transport of Tires Q Notice Of Violation Q Extension <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 EXE <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 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 /> ®In Compliance-No Violations o <br /> Q Q Other:§ <br /> z <br /> Comments <br /> Inspection Form Included: O try-6 <br /> Comments Included:-0 <br /> Business Rep's Si natuw Phone Number In pe r' ignat a Phone Number <br /> INSTRUCTIONS ON BACK Correct:* Incorrect: � � � E X 11213 62081 <br /> ■ White Copy:CalRecycle Yellow Copy:Operator Pink kj/ <br /> ® . <br />