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Waste Tire Su,vey & Inspection Report Inspection Report Number ■ <br /> CalRec cle State of California <br /> Y CalRecycle 181(Rev.10/10) 1 /ey ®r!11i e � � 11 - 1210149 <br /> Dept.of Resources Recycling and Recovery(CalRecycle) M� �/ ��N <br /> Part A-Survey BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- Inspection� � � � J - � ` Inspection Type(Fill one) <br /> Site Suffix: ` b 1 Routine Q Re-inspection 0 Referral Q Observation <br /> LocalC If Referral,choose referral type(Fill one) <br /> Identifier: � � v O CHP Q CalRecycle Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name Inspected By Inspector <br /> Physical Address { � <br /> C �1S2oC� Inspection Date <br /> Time In Time Out <br /> Business Rep Title ®AM O AM <br /> ArkYM tea.e�. � V\ e Q PM 0 PM <br /> 7 Operational Status Tire Type Business Role Storage Type <br /> Tire Count(Whole/PTE) <br /> �y (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> "1 <br /> • Active • Passenger 0 Generator 0 Outdoor <br /> O Q Closed O Altered <br /> GPS Latitude 0 Hauler Q Indoor <br /> O Q Inactive Q Truck <br /> Longitude - Q Planned Q OTR O End-Use O Container <br /> Business Type(Fill all that apply) <br /> Q New Tire Dealer Q Auto Repair Q Trucking Fleet Q Government Q Retreader 0 Dismantler 0 Tire Derived Fuel <br /> Q Used Tire Dealer Q Auto Body Q Car Dealer Q Collection Q Crumb Rubber <br /> 0 Service Station Q Hauler O Agriculture Q Shredder O Other <br /> Part B - Inspection of Waste Tire Dealer, Generator, Hauler and End-Use Facility ENFORCEMENT STATUS <br /> VIA-]HAULING AND MANIFEST REQUIREMENTS <br /> Q Notice Of Violation � Extension <br /> O O <br /> PRC§42951 -Waste Tire Hauler Registration and Transport of Tires <br /> O Q PRC§42953-Contracts with Registered Waste Tire Haulers. Compliance Deadline <br /> PRC§42956-Registration/Decal in Vehicle <br /> 0 O 14 CCR§18459-Responsible Entities Complying with Manifesting Requirements Date M / M / m <br /> O O 14 CCR§18459.1 -Tire Program ID Number from CalRecycle <br /> O O 14 CCR§18459.2.1 -Submittal of Comprehensive Trip Logs within 90 days (Required for NOV or EXT) N <br /> 0 Q 14 CCR§18459.3-Retention of Comprehensive Trip Logs for 3 years <br /> 0 O 14 CCR§18460.2-Manifest System Requirements for Registered Waste Tire Haulers Q Referred/CalRecycle Enforcement <br /> Lu <br /> Q O 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 o <br /> O O Other:§ <br /> Comments <br /> RN V\ <br /> Inspection Form Included: Q L. j L `�� <br /> Comments Included: — �o�` �~��� <br /> Business Rep's Signature Phone Number Insp ctor's Signature Phone Number <br /> 62081 <br /> INSTRUCTIONS ON BACK Correct:0 Incorrect: X E X A M P L E 1 2 3 <br /> ■ White Copy:CalRecycle Yellow Copy:Operator Pink Copy:LEA ® ■ <br />