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Waste Tire Sri. rey & Inspection ReporAbnspection Report Number <br /> State of California <br /> CalRecycle I 1 - 1242201 <br /> CalRecycle 181(Rev.10/10) <br /> (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- I -7 ^ � � �* � - O 1 Inspection Type(Fill one) <br /> Site Suffix: "� 7 4& Routine Q Re-inspection Q Referral Q Observation <br /> Local /�- If Referral,choose referral type(Fill one) <br /> Identifier: �09A�,^ (4��`"'n QyAkr Q CHP Q CalRecycle Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name 1 Inspected By Inspector <br /> C "'C-�1 ons\l�� �'��� n1 - d ` <br /> Physical Address f — 1 <br /> 1\'A5 �- cc�S�vh;�►� C�Ve. <br /> tAQ�'P'_CC' GA 1q-7777 Inspection Date -7 / 2 9 q y <br /> Time In �J Time Out <br /> Business Rep Title O AMO AM <br /> a.�seY, t4� 0 PM ?PM` Operational Status Tire Type Business Role Storage Type <br /> Tire Count(Whole/PTE) <br /> Z (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> 4P Active 0 Passenger e Generator Q Outdoor <br /> O Q Closed Q Altered <br /> GPS Latitude Q Hauler 0 Indoor <br /> O Q Inactive Q Truck <br /> Longitude - Q Planned Q OTR Q End-Use Q Container <br /> Business Type(Fill all that apply) <br /> 4P 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 ! 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 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 EXn N <br /> a <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 /> 2 <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 o <br /> Q Q Other:§ <br /> Comments iM:Vi\ mtcb �!r�' <br /> WC�S �SP�C n �ct�n <br /> L 1,r� cA S <br /> p ~o a 2 <br /> i <br /> Inspection Form Included: Q <br /> Comments Included: <br /> Business Rep's Signature Phone Number Inspe tor's Signature Phone Number <br /> �( <br /> INSTRUCTIONS ON BACK Correct: Incorrect: X � NJ E X A M P L�E 1 2 3 62081 <br /> ■ White Copy:CalRecycle Yellow Copy:Operator Pink Copy:LFA <br />