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Waste Tire purvey & Inspection Rep.orr Inspection Report Number <br /> State of California <br /> CalRecycle I 1 - 1245197 <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 I Inspection Details <br /> TPID- Q / Inspection Type(Fill one) <br /> Site Suffix: ��� ) / v * Routine Q Re-inspection Q Referral Q Observation <br /> Local �^ If Referral,choose referral type(Fill one) <br /> Identifier: Q.n O u n O CHP Q CalRecycle Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name Inspected By Inspector <br /> 6--ecx-c,,k_, <br /> Physical Addres <br /> 13o v <br /> j Inspection Date (1 L / r <br /> Time In Time Out <br /> Business Rep Title /� 1 ®AM / ® AM <br /> • 1 , � U' QPM C / � � O PM <br /> ­ <br /> Operational YhC�,steY <br /> ��1R Operational Status Tire Type Business Role Storage Type <br /> Tire Count /PTE) (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> ® Active Q Passenger ® Generator ® Outdoor <br /> O Q Closed Q Altered <br /> GPS Latitude Q Hauler 0 Indoor <br /> O Q Inactive `Truck <br /> Longitude - Q Planned ® OTR O End-Use Q Container <br /> Business Type(Fill all that apply) <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 O Agriculture Q Shredder 0 Other -As (a t4-- <br /> Part B - Inspection of Waste Tire Dealer, Generator, Hauler and End-Use Facility ENFORCEMENT STATUS <br /> V A HAULING AND MANIFEST REQUIREMENTS <br /> O O PRC§42951 -Waste Tire Hauler Registration and Transport of Tires Notice Of Violation Extension <br /> O O PRC§42953-Contracts with Registered Waste Tire Haulers. Compliance Deadline <br /> PRC§42956-Registration/Decal in Vehicle <br /> O O 14 CCR§18459-Responsible Entities Complying with Manifesting Requirements Date <br /> m / m <br /> O O 14 CCR§18459.1 -Tire Program ID Number from CalRecycle j <br /> O O 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 /> O O 14 CCR§18460.2-Manifest System Requirements for Registered Waste Tire Haulers Q Referred/CalRecycle Enforcement <br /> O O 14 CCR§18461 -Manifest System Requirements for Waste Tire End-Use Facilities w <br /> O O 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators •In Compliance-No Violations o <br /> O O Other:§ <br /> z <br /> Comments ! ` <br /> Inspection Form Included: QCAV9 <br /> Comments Included: lU0 <br /> Business Rep's Signature Phone Number Inspector's Signature Phone Number <br /> INSTRUCTIONS ON BACK Correct:0 Incorrect: � E X A M P L E 1 2 3 62081 <br /> ■ White Copy:CalRecycle Yellow Copy:Operator Pink Copy:LEA © 0 <br />