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Waste Tire <br /> SLAe & Inspection Reportort nspection Report Number <br /> State of California <br /> CalRecycle 181(Rev.10/10) <br /> Survey Form - Page 1 1 - 1242083 <br /> Dept.of Resources Recycling and Recovery(CalRecycle) <br /> Part A- Survey BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- 1 � r' ` ' CA � � _ O .` Inspection Type(Fill one) <br /> Site Suffix: "� "� 1 4j Routine Q Re-inspection Q Referral Q Observation <br /> LocalIf Referral,choose referral type(Fill one) <br /> Identifier: �Q/Y' 5oCLq'%� r W Q Q CHP Q CalRecycle Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name `` r Inspected By Inspector <br /> C�W1�-x �V�!+�Cvcst�OY`/" C_� fc`��rt, <br /> Physical Address LL ?j - d 1 M T <br /> C� 9 S <br /> �� Inspection Date <br /> Time In c, Time Out 1 <br /> Business Rep Title O AM O AM <br /> Gt Z O a PM 0 PM <br /> st� Operational Status Tire Type Business Role Storage Type <br /> Tire Count(Whole/PTE) `3 1 (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> Active Q Passenger Is Generator IS Outdoor <br /> Q Closed Q Altered <br /> GPS Latitude Q Hauler Q Indoor <br /> 0 Q Inactive 4@11 Truck <br /> Longitude - Q Planned Q OTR Q End-Use Q Container <br /> Business Type(Fill all that apply) <br /> Q New Tire Dealer Q Auto Repair 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 m / / 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 EXE 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 /> 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 1 Q Other:§ <br /> Commentse �� b ^te a <br /> `T1 <br /> Inspection Form Included: Q <br /> Comments Included: <br /> Business Rep's Signature hone Number Inspector's Signature Phone Number <br /> INSTRUCTIONS ON BACK Correct:0 Incorrect: E X A M P L E 1112L3] 62081 2 <br /> ■ White Copy:CalRecycle Yellow Copy:Operator Pink Copy:LEA <br />