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Waste Tire SL. ,fey & Inspection Report Inspection Report Number <br /> cle State of California <br /> CalRecycle CalRecycle 181(Rev.10/10) Survey Form - Page 1 11 1230295 <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 Type(Fill one) <br /> Site Suffix: .L l ` ® Routine Q Re-inspection Q Referral Q Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier: O u!t rN (0,_t Q CHP Q CalRecyde Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name Inspected By Inspector <br /> C(A'&L,an L L <br /> Physical Address <br /> Inspection Date <br /> Time In Time Out <br /> Business Rep (� _1 Title <br /> O 0 AM 0 AM <br /> - - -- — - Operational Status Tire Type Business Role Storage Type <br /> Tire Count (Whole/PTE) `1 pl (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> 1 0 Active 0 Passenger 10 Generator ® Outdoor <br /> O Q Closed Q Altered <br /> �PS Latitude Q Hauler 10 Indoor <br /> O Q Inactive • 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 /> 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 /> Q Q 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 /> 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 <br /> Q Q 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators <br /> In Compliance-No Violations o <br /> .0 . 0 Other:§ <br /> z <br /> Comments r <br /> � 0 \1 640,6 pS (A(c at s c - c u n Czpn - <br /> �/gyp vo <br /> Inspection Form �nc <br /> ncluded: H 1 <br /> Comments luded: IO ow IC7 J <br /> Business Rep's Signature Phone Number Inspor's Signature Phone Number <br /> INSTRUCTIONS ON BACK Correct:* Incorrect: � ® � EXAMPLE 1 2 3 62081 <br /> ■ White Copy:CalRecycle Yellow Copy:Operator Pink Copy:LEA © ■ <br />