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Waste Tire Survey & InspecUon Repon Inspection Report Number ■ <br /> CalRec cle State of California <br /> - 1242443Y CalRecycle 181(Rev.10/10) ��/p� ��f?fhYl o Page 1 11 <br /> Dept.of Resources Recycling and Recovery(CalRecycle) r Y e Form <br /> �Il Page <br /> Part A-Survey BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- I C 7 / © ® o O Inspection Type(Fill one) <br /> Site Suffix: J b IS Routine Q Re-inspection Q Referral Q Observation <br /> LocalIf Referral,choose referral type(Fill one) <br /> Identifier: �0.l`N 13160-cU�v-" G*Q — Q CHP Q CalRecycle Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name Inspected By Inspector <br /> rr <br /> Physical Address <br /> 17 l7 W . CV\0_1C_��C_ W 0.7 <br /> � <br /> S Inspection Date C)7� / 1 0 / 1 <br /> S6C�� C1 <br /> Ck � Time In Time Out <br /> Business Rep Title Z 0 AM �c , AM <br /> � s <br /> 41 PM J ' QvoPM <br /> Operational Status Tire Type Business Role Storage Type <br /> Tire Count(Whole/PTE) n (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> L 95 . Active I&Passenger &Generator 40 Outdoo <br /> O Q Closed Q Altered <br /> GPS Latitude Q Hauler 0 Indoor 15 <br /> O Q Inactive Truck <br /> Longitude - Q Planned OTR Q End-Use 0 ContainerZ,I <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 HAULING AND MANIFEST REQUIREMENTS <br /> Q Notice Of Violation Q Extension <br /> Q Q 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 N <br /> Q Q 14 CCR§18459.2.1 -Submittal of Comprehensive Trip Logs within 90 days (Required for NOV or EXT) 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 /> 2 <br /> Q Q 14 CCR§18461 -Manifest System Requirements for Waste Tire End-Use Facilities W <br /> Q Q 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators •In Compliance-No Violations o <br /> Q Q1 Other:§ <br /> Comments <br /> Inspection Form Included: Q <br /> Comments Included: <br /> ftILA �-(16$-3zISq <br /> B siness Rep's Si ture Phone Number Insp tor's Signature Phone Number <br /> INSTRUCTIONS ON BACK Correct:0 Incorrect: X:*�]jEjXjAjMjPjLjEj 111213 1 <br /> 62081 <br /> ® White Copy:CalRecycle Yellow Copy:Operator Pink Copy:LEA ® 0 <br />