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Waste Tire Wey & Inspection Repo Inspection Report Number ■ <br /> State of California <br /> CalRecycle I 1 - 1176412 <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- @Inspection Type(Fill one) <br /> Site Suffix: ; <br /> Q Routine Q Re-inspection Q Referral Q Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier: �c CGLr-V Z Q CHP Q CalRecycle Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name Inspected By Inspector <br /> Physical Address Q I /� €� _ /_ <br /> ( `I YJ ) I rL l d311:.r'L <br /> p <br /> Y_ <br /> - tc �y Inspection Date <br /> � + 1 'v--1i7( Time In Time Out t <br /> Business Rep Title 0 AM Q AM <br /> e O PM X O PM <br /> _Type <br /> - _- - Operational Status�Tire Type Business Role Y) Storage <br /> Tire Count(Whole/PTE) (Fill one only) (Fill all that apply) Fill all that a Fill all that apply) <br /> Q Q Passenger Active Generator Outdoor <br /> GPS Latitude O Q Closed Q Altered <br /> • Q Hauler Q Indoor <br /> O Q Inactive Q Truck <br /> Longitude - <br /> • Q Planned Q OTR Q End-Use I Q Container <br /> Business Type(Fill all that apply) <br /> — ---- <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 /> ® 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 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 IE I]] /V 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 NOor EXT) <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 <br /> Q Q 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators Q In Compliance-No Violations <br /> Q Q Other:§ <br /> Comments +( <br /> �—� -�I 1 '� c.�r-c-�I 41 6 1!(oE�# ��T 4-1 l <br /> `r^.-.� r._.4R'-..P% +. P..�n ti... •W} <[ ..?f: i 9<;1' �'`<Z ,,.•, i:__ `. <br /> Inspection FormIncluded. Q' <br /> Comments Included: Q - - <br /> Business Rep's Signature Phone Number Inspectt is Signature _ Phone Number <br /> - <br /> INSTRUCTIONS ON BACK Correct:0 Incorrect: E X A M PJLJEJ jl3 62oa1 <br /> ■ White Copy:CalRecycle Yellow Copy:Operator Pink Copy:LEA <br />