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02 Waste Tire St., 4ey & Inspection ReporAnspection Report Number <br /> cle State of California <br /> CalRecycle — <br /> Y CalRecycle 181(Rev.10/10) Survey ®rrn - Page I1 1242137 <br /> Dept of Resources Recycling and Recovery(CalRecycle) <br /> Part A-Survey BLUE_ OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- ` O n 6 O I Inspection Type(Fill one) <br /> Site Suffix: 1 "� 0 Routine 0 Re-inspection 0 Referral 0 Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier: �>o'y-\ 1P+,p�o �\Y\ Go"3rk—I 0 CHP , 0 CalRecycle 0 Complaint 0 Educational Visit 0 Other <br /> Business or Facility Name <br /> Inspected By Inspector <br /> Physical Address <br /> Inspection Date 09 / Z _S / <br /> CA cl SzZo Time In Time Out <br /> Busl5ess Title :�I'e r * AM q O AM <br /> b w ( O PM SPM <br /> S c _ <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) (Fill all that apply) <br /> 0 0 Active 0 Passenger 0 Generator 0 Outdo r <br /> . O ;* Closed 0 Altered Hauler Indoor <br /> ry <br /> GPS Latitude O 0 <br /> 0 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 / <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 EX7) n <br /> 0 0 14 CCR§18459.3-Retention of Comprehensive Trip Logs for 3 years <br /> 0 0 14 CCR§18460.2-Manifest System Requirements for Registered Waste Tire Haulers 0 Referred/CalRecycle Enforcement <br /> Ul <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 <br /> in Compliance-No Violations o <br /> 0 10 Other:§ <br /> Comments <br /> ID <br /> s " : I�o6�sb2 <br /> Inspection Form included: 0.1 <br /> Comments Included: 0 .- <br /> Business Rep's Signature Phone Number Inspec or's Signature Phone Number <br /> INSTRUCTIONS ON BACK Correct:10 Incorrect: � NJ E X A M P L E 1112 3 62081 <br /> ® White Copy:CalRecycle Yellow Copy:Operator Pink Copy:LEA ® ■ <br />