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inspection Report Number <br /> Waste Tire Surf, & Mspectlon Report <br /> CalRecycle State of California I 1 - 1245204 <br /> lR <br /> CalRecycle 181(Rev.10/10) ���rvey Form ® Page 1 <br /> Dept of Resources Recycling and Recovery(Caecycle) <br /> Part A-Survey <br /> _ BLUE OR BLACK INK PEN <br /> -- <br /> Business Profile Inspection Details <br /> TPID- �. ] /�. _ Inspection Type(Fill one) <br /> Site Suffix: 1 V Z 2 Q l Routine Q Re-inspection Q Referral Q Observation <br /> Local _ If Referral,choose referral type(Fill one) <br /> Identifier. ScW lj I r) Q CHP Q CalRecycle Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name Inspected By 1 /� Inspector ,,�/�- <br /> Physical Address <br /> r C) / ��(y� (_v o j� ' <br /> coro <br /> Inspection Date •4•- <br /> SI-O"" J Time In Time Out <br /> Business Rep Title i 0 AM <br /> O PM l 0 PM <br /> Q__Cfa9Lf+ P u Z,, Citi - <br /> _. Operational Status Tire Type Business Role Storage type <br /> (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> Tire Count ( ho,Je�PTE) , y' <br /> Active � Passenger ® Generator Q Outdoor <br /> O Q Closed Q Altered <br /> ��� Latitude Q Hauler � Indoor <br /> O Q Inactive Q Truck <br /> Longitude - Q Planned Q OTR Q End Use Q Container <br /> Business Type(Fill all that apply) <br /> New Tire Dealer 40 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 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 <br /> Q Q 14 CCR§18459.1 -Tire Program ID Number from CalRecycle <br /> (Required for NOV or EX7) — N <br /> Q Q <br /> 14 CCR§18459.2.1 -Submittal of Comprehensive Trip Logs within 90 days <br /> Q, 0.--14 CCR§.18459.3-Retention of Comprehensive Trip Logs for 3 years o <br /> Q Q 14 CCR§18460.2-Manifest System Requirements for Registered Waste Tire Haulers Q Referred/CalRecycle Enforcement <br /> Lu <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 /> Inspection Form Included: Q U 20q <br /> %U0374 4(ar- <br /> Comments Included: 0 <br /> Rusin ss a S' ture Phone Number 4nspector's Signature Phone Number <br /> 62081 <br /> INSTRUCTIONS ON BACK Correct:* Incorrect: EXAMPLE 1 2 3 ■ <br /> ■ White Copy:CalRecycle Yellow Copy:Operator Pink Copy:LEA <br />