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Waste Tire Su. Bey & Inspection Repori Inspection Report Number <br /> State of <br /> CalRecycle CalRecycle1ifornia 181(Rev.10/10) ■ <br /> Dept.of Resources Recycling and Recovery(CalRecycle) Survey Form - Page 1 I 1 — 1230373 <br /> Part A-Survey BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- � � a R � Inspection Type(Fill one) <br /> Site Suffix: U • Routine Q Re-inspection Q Referral Q Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier: 0.y TGo_�` Y\ o � OCHP OCalRecvcle 0 Complaint OEducational Visit OOther <br /> Business or Facility Name p p Inspected By Inspector <br /> Physical Address 3 q - O I �� <br /> _ a Inspection Date D 1 / b —I / 1 <br /> Ca CY �� 1 Time In Time Out <br /> Business Rep Title O AM O AM <br /> QPM � �' � QPM <br /> 1� Cil:. lc V:-'S Owv�2� <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 /> ` <br /> 00 • Active 46 Passenger * Generator Q Outdoor <br /> O Q Closed Q Altered <br /> GPS Latitude Q Hauler * Indoor <br /> 0 Q Inactive Q Truck <br /> Longitude _ Q Planned Q OTR O End-Use Q Container <br /> Business Type(Fill all that apply) <br /> New Tire Dealer 0 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 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 /> O 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. I 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 O 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 oe In Compliance- No Violations o <br /> Q Q Other:§ - ` ` -` _ ,, <br /> Comments �1�1�5\RC'2 Zy�StJF� T\01(� �� :5�3� <br /> c�\�c��it`C WctiS _Y\CA4 <br /> 01 t S C7f ��v�C2CV1 <br /> Inspection Form Included: O -�o9%%l J 700 - <br /> Comments Included: VV v <br /> Business Rep's Signature Phone Number Inspector's Signature Phone Number <br /> INSTRUCTIONS ON BACK I Correct:I. Incorrect: X7* q <br /> JEJXJAI M P JLJEJ 1112 3 62081 <br /> ■ White Copy:CalRecycle Yellow Copy:Operator Pink Copy:LEA ® ■ <br />