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03 Waste Tire S*e & Inspection Report Inspection Report Number <br /> CalRecycle y P p _ <br /> State of California <br /> Y CalRecycle 181(Rev.10/10 Survey Form - Page 1 11244928 <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_ © Inspection Type(Fill one) <br /> Site Suffix: 1 ' Routine Q Re-inspection Q Referral 0 Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier: S VA 4r\ J CDC) LA,1 n UD XXr1k 1� 0 CHP Q CalRecycle Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name 1 J <br /> Inspected By Inspector <br /> �, (�I'ern�.k'�ual aper 3 � - , 0 � CS �� <br /> Physical Address <br /> � CA,(, IS��Lo Inspection Date t� GR 1 ` <br /> Time In Time Out <br /> Business Rep Title 1 r� <br /> l O PM V ® PM <br /> Operational Status Tire Type Business Role Storage Type <br /> Tire Count(Whole/PTE) !�( (Fill one only) (Fill all that apply) (Fill all that apply) (FII all that apply) <br /> �J ® Active 0 Passenger 40 Generator Q Outdoor <br /> �� Latitude � <br /> O Q Closed Q Altered 4 <br /> Ca <br /> O Q inactive Q Truck � Hauler Q ISO <br /> Longitude — Q Planned OTR O End-Use Q Container <br /> Business Type(Fill all that apply) aJ <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 <br /> Q Service Station Q Hauler Q Agriculture Q Shredder ® Other PtApv, <br /> Part B- Inspection of Waste Tire Dealer,Generator, Hauler and End-Use Facility ENFORCEMENT STATUS <br /> V A HAULING AND MANIFEST REQUIREMENTS <br /> O O PRC§42951 -Waste Tire Hauler Registration and Transport of Tires O Notice Of Violation O Extension <br /> O O PRC§42953-Contracts with Registered Waste Tire Haulers. Compliance Deadline <br /> O O PRC§42956-Registration/Decal in Vehicle <br /> O O 14 CCR§18459-Responsible Entities Complying with Manifesting Requirements Date <br /> O O 14 CCR§18459.1 -Tire Program ID Number from CalRecycle <br /> O O 14 CCR§18459.2.1 -Submittal of Comprehensive Trip Logs within 90 days (Required for NOV or EXT) N <br /> A <br /> Q Q 14 CCR§18459.3-Retention of Comprehensive Trip Logs for 3 years o <br /> O O 14 CCR§18460.2-Manifest System Requirements for Registered Waste Tire Haulers Q Referred/CalRecycle Enforcement <br /> 2 <br /> O O 14 CCR§18461 -Manifest System Requirements for Waste Tire End-Use Facilities W <br /> O O 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators In Compliance-No Violations o <br /> Q O1 Other:§ <br /> Comments <br /> 6 CA <br /> Inspection Form Included � /Comments Included: / "1 tz�siness ws Sig ature Phone Number Inspe isSignatu hone <br /> 62081 <br /> INSTRUCTIONS ON BACK .Correct: Incorrect: E X A M P L 1 2 3 <br /> ■ White Copy:CalRecycle Yellow Copy:Operator Pink Copy:1 <br /> ® 0 <br />