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Waste Tire S 'y & Inspection Repor ispection Report Number <br /> Cal Recycle State of California 1 - 1176642 <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- 1 _ Inspection Type(Fill one) <br /> Site Suffix: -1 u o ` ® Routine 0 Re-inspection Q Referral Q Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier: , O CHP Q CalRecycle Q Complaint O Educational Visit Q Other <br /> Business or Facility Name 1 VU Inspected By Inspector <br /> �( L' 1 (2, �e tin <br /> Physical Address q l i a <br /> Inspection Date 13 <br /> Time In Time Out <br /> Business Rep Title ®AM O AM <br /> I l • 3 0 QPM a o 0 P M <br /> rw f n' V Ctq 1 hQ © `CO- — Operational Status Tire Type Business Role Storage Type <br /> The Count(Whole/PTE) (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> ® Active ® Passenger ® Generator Q Outdoor <br /> O Q Closed Q Altered <br /> GPS Latitude Q Hauler Q Indoor <br /> O Q Inactive 0 Truck <br /> Longitude - Q Planned Q OTR O End-Use ® Container <br /> Business Type(Fill all that apply) <br /> Q New Tire Dealer Q Auto Repair 0 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 ® Hauler Q Agriculture Q Shredder Q Other <br /> Part B - Inspection of Waste Tire Dealer, Generator, Hauler and End-Use Facility ENFORCEMENT <br /> FORCEMENT STATUS <br /> V A HAULING AND MANIFEST REQUIREMENTS <br /> - - - - - ------ Q Notice Of Violation 0 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 /> 0 0 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 O 14 CCR§18459.2.1 -Submittal of Comprehensive Trip Logs within 90 days (Required for NOV or EX ) N <br /> O O 14 CCR§18459.3-Retention of Comprehensive Trip Logs for 3 years o <br /> O Q 14 CCR§18460.2-Manifest System Requirements for Registered Waste Tire Haulers Q Referred/CalRecycle Enforcement <br /> 0 Q 14 CCR§18461 -Manifest System Requirements for Waste Tire End-Use Facilities W <br /> O O 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators ®In Compliance-No Violations <br /> O Q Other:§ - J <br /> Comments <br /> �1.y�'yVtc�1 �tl,CZ�� •�,,•� G�� _!-s,t.��.L f'-�.�t� _ .� <br /> Inspection Form Included: Q X <br /> Comments Included: � K—ure <br /> Bu • ess Re Phone Number 4n' ecr sSignature Phone Number <br /> INSTRUCTIONS ON BACK Correct a Incorrect: X �0 E X A P L f�r 1112131 62081 <br /> White Copy:CalRecycle Yellow Copy:Operator Pink py: <br />