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Waste Tire Su%ey & Inspection RepoA Inspection Report Number ■ <br /> CalRecycle State of California J <br /> Y CalRecycle 181(Rev.10/10) C�I�l1f/ y Form} ® �� � 11 1196572 <br /> Dept.of Resources Recycling and Recovery(CalRecycle) Su� 'V�e ��u <br /> Part A-Survey BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> 7PID- � r � �•- � � � o O Y Inspection Type(Fill one) <br /> Site Suffix: 7 J I 0 Routine 0 Re-inspection 0 Referral 0 Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier: 0 CHP 0 CalRecycle 0 Complaint 0 Educational Visit 0 Other <br /> Business or Facility Name Inspected By Inspector <br /> Physi6e7P\Address <br /> 3 1 0 �fi� y <br /> V . <br /> Inspection Date _ / 30 1 3 <br /> 5� <br /> C�6Y`\ �� `—1�2 Time In Time Out <br /> Business Rep Title ® *AM AM <br /> Q PM I 1 Z 0 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 0 Passenger 40 Generator 40 Outdoor <br /> O 0 Closed 0 Altered <br /> o�� Latitude 0 Hauler 0 Indoor <br /> 0 0 Inactive a Truck <br /> Longitude - 0 Planned 0 OTR 0 End-Use * Container <br /> Business Type(Fill all that apply) <br /> 0 New Tire Dealer 0 Auto Repair 0 Trucking Fleet 0 Government 0 Retreader 0 Dismantler 0 Tire Derived Fuel <br /> 0 Used Tire Dealer 0 Auto Body 0 Car Dealer 0 Collection 0 Crumb Rubber <br /> 0 Service Station 0 Hauler 0 Agriculture 0 Shredder • Other ��@Ck„�q` <br /> Part B- Inspection of Waste Tire Dealer, Generator, Hauler and End-Use Facility ENFORCEMENT STATUS <br /> V A I HAULING AND MANIFEST REQUIREMENTS <br /> O O 0 Notice Of Violation 0 Extension <br /> PRC§42951 -Waste Tire Hauler Registration and Transport of Tires <br /> 0 0 PRC§42953-Contracts with Registered Waste Tire Haulers. Compliance Deadline <br /> PRC§42956-Registration/Decal in Vehicle <br /> 0 0 14 CCR§18459-Responsible Entities Complying with Manifesting Requirements Date m / m / m <br /> 0 0 14 CCR§18459.1 -Tire Program ID Number from CalRecycle <br /> 0 0 14 CCR§18459.2.1 -Submittal of Comprehensive Trip Logs within 90 days (Required for NOV or E)C7) N <br /> 0 0 14 CCR§18459.3-Retention of Comprehensive Trip Logs for 3 years o <br /> 0 0 14 CCR§18460.2-Manifest System Requirements for Registered Waste Tire Haulers 0 Referred/CalRecycle Enforcement <br /> 2 <br /> 0 0 14 CCR§18461 -Manifest System Requirements for Waste Tire End-Use Facilities <br /> 0 0 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators .In Compliance-No Violations o <br /> 0 0 Other:§ <br /> Comments w>� � <br /> Inspection Form Included: 0 .n- <br /> Comments Included: O U 7 <br /> Business ep's Signature Phone Number Inspector's Signature Phone Number <br /> 62081 <br /> INSTRUCTIONS ON BACK [Correct- Incorrect: � � � E X A M P L E 11.12 <br /> ® White Copy:CalRecycle Yellow Copy:Operator Pink Copy:LEA © ■ <br />