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Waste Tire S e & Inspection Re o,"nspection Report Number <br /> CalRecyclep P _ <br /> State of CaliforniaCaI'dornia <br /> Y CalRecycle 181(Rev.10/10) Survey Form - Page 1 1 1210121 <br /> Dept.of Resources Recycling and Recovery(CalRecycle) <br /> Part A-Survey BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- 0e� O 2 m O Inspection Type(Fill one) <br /> Site Suffix: / (� •Routine Q Re-inspection Q Referral Q Observation <br /> Local ) l If Referral,choose referral type(Fill one) <br /> Identifier: S C\0 1^ �,t `)11 Q CHP Q CalRecycle Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name �— Inspected By Inspector <br /> CD �OTT <br /> Physical Addres 1 <br /> '?)b T7 b_-� s_ (�4A 6U U\, <br /> Inspection Date <br /> CA GS�)�'k $ 5 1 3 <br /> Time In vv Time Out <br /> Business Rep Title O AM Q O AM <br /> HumUr 9-C-C_'O' t Is PM ® PM <br /> - <br /> -- - Operational Status Tire Type Business Role Storage Type <br /> Tire Count (Whole/PTE) O (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> ®Active 0 Passenger ® Generator a Outdoor <br /> GPS Latitude , <br /> O Q Closed Q Altered <br /> Hauler Q Indoor <br /> o Q Inactive S Truck <br /> Longitude - Q Planned Q OTR Q 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 ® Collection Q Crumb Rubber <br /> Q Service Station ® Hauler Q Agriculture Q Shredder ® Other Ic-In9irl- <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 Q --- Q Notice Of Violation Q Extension <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 /> 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 N <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 /> 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 <br /> ®In Compliance-No Violations o <br /> Q Q Other:§ <br /> Comments cc�_ ; <br /> Noy i0 )�00<. (21 <br /> Inspection Form Included. Q U1'3 5(r ty� <br /> Comments Included: ® D — [. V <br /> jsi4ness Rep's Signature Phone Number Insp or's Signature Phone Number <br /> INSTRUCTIONS ON BACK I Correct-* Incorrect: _j EXAM L 1 2 3 62081 <br /> ■ White Copy:CalRecycle Yellow Copy:Operator Pink Copy.LFA ® ■ <br />