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0 Waste Tire Sul vey & Inspection Ffolmpo Inspection Report Number ■ <br /> CalRecycle state of California I 1 - 1242106 <br /> CalRecycle 181(Rev.10/10) Cui�i/®y �0��^-P — Page <br /> Dept of Resources Recycling and Recovery(CalRecycle) V r Y e u 111 i��i ii <br /> Part A-Survey <br /> BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- Inspection Type(Fill one) <br /> Site Suffix: 0 Routine Q Re-inspection Q Referral Q Observation <br /> Local \_ If Referral,choose referral type(Fill one) <br /> Identifier: SCL�I �C�[ic� (� C�L►�- Q CHP Q CalRecycle Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name ll Inspected By Inspector <br /> Physical Address `-I y ( (�iyy <br /> >LILA <br /> /90 <br /> Inspection Date i <br /> � G L 15�s UUO <br /> Time In Time Out <br /> Business Rep Title AM r AM <br /> ��r � o� / 0 :� U O PM / C[ O PM <br /> V Cu GES 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 /> ->�'— Q Active Q Passenger Q Generator Q Outdoor <br /> GPS Latitude O ® Closed Q Altered Q Hauler Q Indo <br /> 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 Q Trucking Fleet a 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 / 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 EX7) 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 /> w <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 _ <br /> L;=� <br /> .Comments Included: <br /> usiness Rep's Signature PhbI r ig ture Phone Number <br /> INSTRUCTIONS ON BACK Correct:* Incorrect: E X A M L E 1 2 3 62081 <br /> ■ White Copy:CalRecycle Yellow Copy:Operator Pink Copy:LEA ® ■ <br />