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M Waste Tire Sur vey & Inspection Report Inspection Report Number ■ <br /> Cal Rec cle State of California <br /> Y CalRecycle 181(Rev.10/10) Survey ®rrni ® Page 'I! 11 1177818 <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 1 Inspection Type(Fill one) <br /> Site Suffix: _I �j p Routine Q Re-inspection Q Referral Q Observation <br /> LocalIf Referral,choose referral type(Fill one) <br /> Identifier: (��p(, JIAI n (O�A Q CHP Q CalRecycle Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name Inspected By Inspector <br /> LIT <br /> Physical Address 1 0 k F 5 <br /> Inspection Date <br /> Time In Time Out <br /> Business Rep Title 1 O 0 AM I 0 AM <br /> APM ® PM <br /> V 1t f i•(�i!n U��► L4CI��U 041�C� m <br /> Operational Status Tire Type Business Role Storage Type <br /> Tire Count(Whole/PTE) (Fill ond'only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> • Active S Passenger Q Generator Q Outdoor <br /> O Q Closed Q Altered N i4 <br /> GPS Latitude • Hauler Q Indoor <br /> O Q Inactive 0 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 Q Collection Q Crumb Rubber <br /> Q Service Station 4D 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 / Ffl / m <br /> Q Q 14 CCR§18459.1 -Tire Program ID Number from CalRecycle <br /> . 0 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 /> 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 /> 01 Q Other:§ <br /> Commentsy�_ �� T_ _,},, 1„) <br /> -C711G�a�c_ plc. 1 rz11i� y\o ( !Am(A Thc <br /> Uj-els no�� - <br /> N Or (A IQ 46,S O CO-�Ccrn. <br /> Inspection Form Included: Q Avlw <br /> Comments Included: <br /> 'Busines g e Phone Number 41. peY.I.Signature Phone Number <br /> INSTRUCTIONS ON BACK Correct:* Incorrect: M ® VEXAMPLE 1 2 3 62081 <br /> ® White Copy:CalRecycle Yellow Copy:Operator Pink Copy:LEA ® ■ <br />