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Waste Tire Avey & Inspection Repor ,, Inspection Report Number <br /> CalRec cle State of California <br /> Y CalRecycle 181(Rev.10/10) 11 1245202 <br /> Dept of Resources Recycling and Recovery(CalRecycle) Survey Form - Page 1 <br /> BLUE OR BLACK INK PEN <br /> Part A- <br /> Business Profile Inspection Details <br /> TPID- pection Type(Fill one) <br /> Site Suffix: Q � 3 �Routine QRe-inspection Q Referral <br /> Observation <br /> Local — If Referral,choose referral type(Fill one) <br /> Identifier: r J 0 `n 6� Q CHP Q CalRecycle Q Complaint Q Educational Visit Q Other <br /> Business oor�r Facility Name Inspected By Inspector <br /> Physical Addrreess C�� GC b 1 MAT TQ <br /> Inspection Date /� "� / 7 1 S <br /> %_ 9 SZI / <br /> Time In Time Out <br /> Business Rep Titleu , O 0 AM ' O AM <br /> TT.T, 0 PM ®PM <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 /> Active * Passenger &Generator 0 Outdoor2G <br /> O Q Closed Q Altered <br /> GPS Latitude Q Hauler Q Indoor <br /> O Q Inactive '* Truck <br /> Longitude - Q Planned Q OTR Q End-Use Container <br /> Business Type(Fill all that apply) <br /> Q New Tire Dealer Q Auto Repair 40 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 B - Inspection of Waste Tire Dealer, Generator, Hauler and End-Use Facility ENFORCEMENT STATUS <br /> V A 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 /> PRC§42956-Registration/Decal in Vehicle <br /> Q Q 14 CCR§18459-Responsible Entities Complying with Manifesting Requirements Date <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 EX7) N <br /> a <br /> N <br /> Q Q 14 CCR§18459.3-Retention of Comprehensive Trip Logs for 3 years <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 /> OLC&Ae . A<-p 1w5p4e"L'r -&pec? r3 in <br /> v\ f <br /> Inspection Form Included: Q V If` "- r v c ��%Gl _` Q�O�cJ2 <br /> Comments Included: ��-� <br /> Business Rep's Si t is ature Phone Number InspecSignature Phone Number 114 <br /> �,( <br /> INSTRUCTIONS ON BACK Correct:0 Incorrect: X NJ EXAM P E 1 2 3 62081 <br /> ■ White Copy:CalRecycle Yellow Copy:Operator Pink Copy L © ■ <br />