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Waste Tire Survey & Inspection Rep©n Inspection Report Number <br /> State of California <br /> CalRecycle CalRecycle 181(Rev.10/10) Su��cyortYl ® [gage I1 0 1242412 <br /> Dept.of Resources Recycling and Recovery(CalRecycle) <br /> Part A-Survey _ _- -_ BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- Inspection Type(Fill one) <br /> Site Suffix: ( JI-- Ct Z 7 ( (D Routine Q Re-inspection Q Referral Q Observation <br /> Local \ If Referral,choose referral type(Fill one) <br /> Identifier: ��h ,CaCtt�V�'1 Q CHP Q CalRecycle Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name Inspected By Inspector <br /> Physica'I/�d'dr" C) l'j, <br /> n Inspection Date / S G) / l f <br /> Time In Time Out LL <br /> Business Rep Title ®AM AM <br /> F I{ ' 0 0 © PM l � c2 S O PM <br /> ^ra, allec��c._ <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 /> C) 0 Active ® Passenger ® Generator aOutdoor <br /> o Q Closed Q Altered <br /> ��� Latitude Q Hauler Q Indoor <br /> O Q Inactive ® Truck <br /> Longitude - Q Planned Q OTR Q End-Use Q Container <br /> Business Type(Fill all that apply) <br /> ® New Tire Dealer Q Auto Repair Q Trucking Fleet Q Government Q.Retreader Q Dismantler Q Tire Derived Fuel <br /> 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 B - Inspection of Waste Tire Dealer, Generator, Hauler and End-Use Facility ENFORCEMENT STATUS <br /> V A I 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 /> Q Q 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 Q 14 CCR§18459.2.1 -Submittal of Comprehensive Trip Logs within 90 days (Required for NOV or EXE N <br /> - N <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 /> W <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 /> Q Q Other:§ <br /> Comments <br /> Cmewc N <br /> ( <br /> Inspection Form Included: Q <br /> Comments Included:® <br /> Business Rep's Signature Phone Number Ins or gnature Phone Number <br /> INSTRUCTIONS ON BACK Correct:* Incorrect: _ 4 EXAM E 2 3 62081 <br /> ■ White Copy:CalRecycle Yellow Copy:Operator Pink Cop �LE ■ <br />