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Waste Tire Ivey & <br /> Inspectionection Re or , Inspection Report Number <br /> rniaCState of California <br /> alRecycleCalRecycle 181(Rev.10/10) <br /> purvey Form - gage 1 1 1245073 <br /> Dept.of Resources Recycling and Recovery(CalRecycle) <br /> Part A-Survey BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- Inspection i � � � � _ � � Inspection Type(Fill one) <br /> Site Suffix: •Routine 0 Re-inspection 0 Referral 0 Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier: McQqo'l 0 0Ctv'V-L 0 CHP 0 CalRecycle 0 Complaint 0 Educational Visit 0 Other <br /> Business or Facility Name-�- Inspected By Inspector <br /> �y b co"� I I ®� ��CQ(1�L�� 0.1 _ 1 f l �/� , <br /> Physical Address q 3 / ° ��-� I"OGf F 5� <br /> C Inspection Date / L( / <br /> Time In Time Out <br /> Business Rep Title AM O AM t ® PM O PM <br /> - Operational Status Tire Type Business Role Storage Type <br /> Tire Coun hole TE) <br /> (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> 0 Active 0 Passenger S Generator 0 Outdoor <br /> O 0 Closed 0 Altered <br /> GPS Latitude 0 Hauler O Indoor <br /> O 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 Notice Of Violation 0 Extension <br /> 0 0 PRC§42951 -Waste Tire Hauler Registration and Transport of Tires <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 <br /> 0 0 14 CCR§18459.2.1 -Submittal of Comprehensive Trip Logs within 90 days (Required for NOV or EJ(7) <br /> 0 0 14 CCR§18459.3-Retention of Comprehensive Trip Logs for 3 years d <br /> 0 0 14 CCR§18460.2-Manifest System Requirements for Registered Waste Tire Haulers 0 Referred/CalRecycle Enforcement <br /> W <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 o <br /> 0 0 Other:§ _ <br /> Comments <br /> LIC) <br /> Inspection Form Included: 0 7�E [/ice D•� <br /> Comments Included: ( <br /> Busin ature Phone Number Inspector's Signature Phone Number <br /> INSTRUCTIONS ACK Correct:0 Incorrect: ___�7jEjXjAjMjPjLjEj 1112 3 62081 <br /> ■ White Copy:CalRecycle Yellow Copy:Operator Pink Copy:LEA ® ■ <br />