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Waste Tire Soy Bey & Inspection Report inspection Report Number <br /> CalRecycle of CaalRecycle1ifornia 181(Rev.10/10) I 1 - 119 6 7 3 6 <br /> Dept.of Resources Recycling and Recovery(CalRecycle) Survey Form - Page 1 <br /> Part A-Survey BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- � I � � � 'Z � - O � Inspection Type(Fill one) <br /> Site Suffix: b 0 Routine 0 Re-inspection 0 Referral 0 Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier. SC Y'\ ��n p %-5 r Co%Z)Y\ 0 CHP 0 CalRecycle 0 Complaint 0 Educational Visit 0 Other <br /> Business or Facility Name h Inspected By Inspector <br /> fin; Cal MoNJ-\r <br /> Physical Address <br /> 6 d7 C.-c\ko\r\ (3-\.)er Sk-r_ 'g <br /> Inspection Date h / 2 / 1 <br /> 5 �oc���ov� C� gS2b3 lJ <br /> I <br /> Time In Time Out <br /> Business Rep Title ' Q 0 AM Q AM <br /> ` � U <br /> Div r\ Ps✓ �QPM � Z 0 0 PM <br /> GjVr70.Y1 �w•oh� <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 /> 0 Active 0 Passenger * Generator 0 Outdoor <br /> GPS Latitude O 0 Closed 0 Altered ' <br /> 0 Hauler 0 dor <br /> 0 0 Inactive 0 Truck <br /> Longitude - 0 Planned 0 OTR 0 End-Use 0 Container <br /> Business Type(Fill all that apply) <br /> 0 New Tire Dealer 0 Auto Repair 0 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 <br /> Part B - Inspection of Waste Tire Dealer,Generator, Hauler and End-Use Facility ENFORCEMENT STATUS <br /> V A HAULING AND MANIFEST REQUIREMENTS <br /> 0 0 PRC§42951 -Waste Tire Hauler Registration and Transport of Tires Notice Of Violation Extension <br /> 0 0 PRC§42953-Contracts with Registered Waste Tire Haulers. Compliance Deadline <br /> PRC§42956-Registration/Decal in Vehicle <br /> 0 0 14 CCR§18459-Responsible Entities Complying with Manifesting Requirements Date m / m / m <br /> 0 0 14 CCR§18459.1 -Tire Program ID Number from CalRecycle co <br /> 0 0 14 CCR§18459.2.1 -Submittal of Comprehensive Trip Logs within 90 days (Required for NOV or EXE n <br /> 0 0 14 CCR§18459.3-Retention of Comprehensive Trip Logs for 3 years <br /> 0 <br /> 0 0 14 CCR§18460.2-Manifest System Requirements for Registered Waste Tire Haulers 0 Referred/CalRecycle Enforcement <br /> 2 <br /> 0 0 14 CCR§18461 -Manifest System Requirements for Waste Tire End-Use Facilities w <br /> 0 0 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators In Compliance-No Violations <br /> 0 0 Other:§ _. <br /> Comments <br /> p �Om, e.C- <br /> Inspection Form Included: 0 �043 <br /> ®r's Comments Included: <br /> B ine p's ign ure Phone Number InspecSignature Phone Number <br /> INSTRUCTION ON BACK Correct:0 Incorrect: ® � IEIXIAIMIPILIEI 11 2 3 62081 <br /> ■ White Copy:CalRecycle Yellow Copy:Operator Pink Copy:LEA ® ■ <br />