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Waste Tire St.. Bey & Inspection Reporolnspection Report Number <br /> CalRecycle State of California I 1 - 1230065 <br /> . CalRecycle 181(Rev.10/10) Survey dorm - Page 1- <br /> Dept of Resources Recycling and Recovery(CalRecycle) <br /> BLUE OR BLACK INK PEN <br /> Part A-Survey <br /> Business Profile Inspection Details <br /> TPID- � ^ � � ^ � _ p� � Inspection Type(Fill one) <br /> � ` <br /> Site Suffix: ` �J 10 Routine 0 Re-inspection 0 Referral 0 Observation <br /> Local MCC If Referral,choose referral type(Fill one) <br /> Identifier: 0Ck_jt9,Y1 COO 0 CHP 0 CalRecycle 0 Complaint 0 Educational Visit 0 Other <br /> Business or Facility Name r Inspector <br /> � <br /> Inspected By m p <br /> Physical Address ` �I <br /> Inspection Date O s <br /> Time In Time OutJ <br /> Business Rep Title O AM O AM <br /> 4W PM Oopl,PM <br /> Ns ' ` ` 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 /> S Active 0 Passenger •Generator 0 Outdoor <br /> 0 Closed 0 Altered <br /> GPS Latitude 0 Hauler Indoor <br /> 0 0 Inactive 0 Truck <br /> Longitude - 0 Planned 4@1 OTR 0 End-Use 0 Container <br /> Business Type(Fill all that apply) <br /> 0 New Tire Dealer 0 Auto Repair ® 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 0 Other �S- �j� c�T� ozy-At <br /> Part B- Inspection of Waste Tire Dealer, Generator, Hauler and End-Use Facility ENFORCEMENT STATUS <br /> V I A HAULING AND MANIFEST REQUIREMENTS <br /> 0 0 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 /> 0 0 PRC§42956-Registration/Decal in Vehicle <br /> 0 0 14 CCR§18459-Responsible Entities Complying with Manifesting Requirements Date m co <br /> / 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 EX7) <br /> r <br /> v <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 /> Lu <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 le In Compliance-No Violations o <br /> 0 0 Other:§ <br /> Comments <br /> l9� ih p <br /> Inspection Form Included: X32 D <br /> Comments Included: <br /> Bu ness p's Signature Phone Number Inspect is Signature Phone Number <br /> INSTRUCTIONS ON BACK Correct: Incorrect: JEjXjAjMjP_'j_LjEj 111251 <br /> 62081 <br /> White Copy:CalRecycle Yellow Copy:Operator Pink Copy:LEA <br />