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Waste Tire 5.., .ey & Inspection Repospection Report Number <br />State of <br />CalRecycle CalRecycle1ifornia 181 (Rev. 10/10)11 -1176543 <br />Dept. of Resources Recycling and Recovery (CalRecycle) Survey Form - Page 1 <br />n-" � �..�,,.., BLUE OR BLACK INK PEN <br />Business Profile <br />Inspection Details <br />TPID - <br />Site Suffix: r L 44 2® 0 1 <br />Inspection Type (Fill one) <br />Q Routine Is Re -inspection Q Referral Q Observation <br />If Referral, choose referral type (Fill one) <br />Local <br />Identifier: 5�X, vr�` �-�'vyv `t <br />Q CHP Q CalRecycle Q Complaint Q Educational Visit Q Other <br />Business or Facility Name <br />Inspected By Inspector <br />Phys;LtG(� ?C tT �ruc=lam'; VLA <br />, A <br />L^ddress % <br />P\Ve, . <br />Inspection Date <br />Time In Time Out <br />Business Rep Title <br />O AM _ O AM <br />3 a3 v ® PM '� L' PM <br />Operational Status Tire Type Business Role Storage Type <br />that that appy) <br />Tire Count (V1/hole/PTE) I I <br />' <br />(Fill one only) (Fill all that apply) (Fill all apply) (Fill all <br />0 Active Q Passenger ® Generator ® Outdoor <br />Q Closed Q Altered <br />Q Hauler ® Indoor <br />O <br />GPS Latitude <br />Q Inactive ®Truck <br />O <br />Longitude - <br />Q Planned Q OTR Q End -Use Q Container <br />Business Type (Fill all that apply) <br />Q New Tire Dealer Q Auto Repair ® 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 Q Hauler Q Agriculture Q Shredder Q Other <br />Part <br />B - <br />Inspection of Waste Tire Dealer, Generator, Hauler and End -Use Facility <br />ENFORCEMENT STATUS <br />Q Notice Of Violation Q Extension <br />V <br />A <br />HAULING AND MANIFEST REQUIREMENTS" <br />Q <br />Q <br />PRC § 42951 - Waste Tire Hauler Registration and Transport of Tires <br />Q <br />Q <br />PRC § 42953 - Contracts with Registered Waste Tire Haulers. <br />Compliance Deadline <br />Q <br />Q <br />PRC § 42956 - Registration/Decal in Vehicle <br />Q <br />Q <br />14 CCR § 18459 - Responsible Entities Complying with Manifesting Requirements <br />Date m <br />Q <br />Q <br />14 CCR § 18459.1 - Tire Program ID Number from CalRecycle <br />Q <br />Q <br />14 CCR § 18459.2.1 - Submittal of Comprehensive Trip Logs within 90 days <br />(Required for NOV or EXT) <br />Q <br />Q <br />14 CCR § 18459.3 - Retention of Comprehensive Trip Logs for 3 years <br />Q <br />Q <br />14 CCR § 18460.2 - Manifest System Requirements for Registered Waste Tire Haulers <br />Q Referred / CalRecycle Enforcement <br />Q <br />Q <br />14 CCR § 18461 - Manifest System Requirements for Waste Tire End -Use Facilities <br />Q <br />Q <br />14 CCR § 18462 - Manifest System Requirements for Tire Dealers or Waste Tire Generators <br />® In Compliance - No Violations <br />Q <br />Q <br />Other: § <br />Comments /K.C_ � n c �v� t v� C IYL-- _A4 i <br />Inspection Form Included: Q <br />X ' <br />Comments Included: <br />_Ti /Lc- CZa�'� �IGZi'—oGZ3 <br />— <br />Business Rep's Signa re Phone mber Inspector's Signatur Phone Number <br />INSTRUCTIONS ON BACK <br />Correct: Incorrect: <br />E <br />X <br />A <br />L <br />1 <br />2 <br />3 <br />62081 <br />IL <br />0 White Copy: CalRecycle Yellow Copy: Operator Pink Cop 7 <br />■ <br />