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Waste Tire Ste, vey & Inspection Repokt inspection Report 4umber . <br /> CalRec cle State of California <br /> Y CalRecycle 181(Rev.10/10) Survey Form - Page 1 I1 - 1176714 <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: l v 3 * Routine Q Re-inspection Q Referral Q Observation <br /> Local `��- �� If Referral,choose referral type(Fill one) <br /> Identifier: Y� J Q CHP Q CalRecycle Q Complaint Q Educational Visit Q Other <br /> SCXBusiness or Facility Name Inspected By Inspector <br /> 7r�. �Ch�� 1:.�� 2 a _ <br /> Physical Addres 3J 1 l 0 l <br /> 3lEco &hu P'���z��. f-J� . <br /> Inspection Date / C� <br /> CA <br /> Tri C R53o� Time In Time Out l <br /> Business Rep Title O AMO AM <br /> ® <br /> L� ® PM r r � ® 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 /> ' ' 0? ® Active ® Passenger Generator ® Outdoor <br /> D Q Closed Q Altered <br /> GPS Latitude Q Hauler Q 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 /> ® 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 a <br /> Q Q 14 CCR§18459.2.1 -Submittal of Comprehensive Trip Logs within 90 days (Required for NOV or EXT) 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 /> W <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 ®In Compliance No Violations o <br /> Q Q Other:§ <br /> Comments ` <br /> `�P��P�✓�1_YY_l� - N <br /> Inspection Form Included: Q <br /> Comments Included- Bt <br /> sin ep's Signature Phone Number 4sit r' S nature Phone Number <br /> 62081 <br /> INSTRUCTIONS ON BACK Correct:0 Incorrect: E A L 1 2 3 <br /> ■ White Copy:CalRecycle Yellow Copy:Operator Pink Cop : ■ <br />