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Waste Tire '49key Mnspection Repots Inspection Report Number <br /> cle State of California <br /> CalRecycle — <br /> Y CalRecycle 181(Rev.10/10) �1 1245218 <br /> Dept.of Resources Recycling and Recovery(CalRecycle) Survey Form - Page <br /> Part A-Survey BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- /J„ /� _ ( Inspection Type(Fill one) <br /> Site Suffix: U '7 / (-,i c ( ® Routine Q Re-inspection Q Referral Q Observation <br /> Local �,y�,, If Referral,choose referral type(Fill one) <br /> Identifier: (� ��'? CQ CHP Q CalRecycle Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name Inspected By Inspector <br /> Physical Address ATL 1 l C SIJ 1 uf!✓V hIT L <br /> �� L� ��,y� Inspection Date �--/ � ^ / <br /> GV�C Time In Time Out <br /> V <br /> Business Rep Title .,(Jk / ( AM SAM <br /> ~ O PM Q PM <br /> Operational Status Tire Type Business Role Storage Type <br /> Tire Counthole/PTE) (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> W <br /> I ® Active Q Passenger 116 Generator • Outdoor 1 <br /> o Q Closed Q Altered <br /> GPS Latitude Q Hauler Q Indoor <br /> O Q Inactive Q Truck <br /> Longitude — Q Planned OTR Q End-Use Q Container <br /> Business Type(Fill all that apply) <br /> Q New Tire Dealer Q Auto Repair Q 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 ? �f i <br /> Q Service Station Q Hauler Q Agriculture Q Shredder ® Other (� d "► <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 /> QQ 14 CCR§18459-Responsible Entities Complying with Manifesting Requirements Date 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 EXT) <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 /> 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 Q Other:§ <br /> Comments U-21 . [, td I f <br /> 4-�` 1.Po� Y 16Q-�`— c�� l LGLVJ <br /> l �) <br /> Inspection Form Included: O ! e <br /> Comments Included: <br /> Business Rep's Signature Phone Number Inspector's Signature Phone Number <br /> INSTRUCTIONS ON BACK [Correct: Incorrect: NA NJ E X A M P L E 1 2 3 62081 <br /> White Copy:CalRecycle Yellow Copy:Operator Pink Co y L <br />