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Waste Tire Su. Bey & Inspection Report inspection Report Number <br /> CalRec cle State of California — <br /> Y CalRecycle 181(Rev.10/10) Surve�9Form o page 11 1178024 <br /> Dept of Resources Recycling and Recovery(CalRecycle) <br /> Part A-Survey BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- ` r G _ © 1 Inspection Type(Fill one) <br /> Site Suffix: ` lq 1 I 0 Routine 0 Re-inspection 0 Referral 0 Observation <br /> Local , If Referral,choose referral type(Fill one) <br /> Identifier: SU 11 �� Il�� rN C(�U /� 0 CHP 0 CalRecycle 0 Complaint 0 Educational Visit 0 Other <br /> Business or Facility Name Inspected By Inspector <br /> Physical Address (040 <br /> �C_ <br /> Inspection Date / (D <br /> Time In Time Out <br /> Business Rep Title 0 AM 0 AM <br /> O Q ® PM Q, � Q ® PM <br /> Operational Status Tire Type Business Role Storage Type <br /> Tire Count(Whole/PTE) <br /> (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> � y <br /> 0 Active 0 Passenger ® Generator 0 Outdoor <br /> 0 0 Closed 0 Altered O)A <br /> GPS Latitude 0 Hauler 0 Indoor <br /> D 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 • 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 /> Q Notice Of Violation � Extension <br /> 0 0 <br /> 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 <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 EXT) <br /> 0 0 14 CCR§18459.3-Retention of Comprehensive Trip Logs for 3 years o <br /> 0 0 14 CCR§18460.2-Manifest System Requirements for Registered Waste Tire Haulers 0 Referred/CalRecycle Enforcement <br /> Lu <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 1 0 1Other:§ <br /> 1r <br /> Comments 4j� 41 �1�►r�7nV11 <br /> Inspection Form Included: Q � �,� <br /> Comments Included: 0 <br /> Business Rep's Signature Phone Number %nsjpior'sSignature Phone Number <br /> INSTRUCTIONS ON BACK Correct: Incorrect: � W E X A M P L E 2 3 62081 <br /> ■ White Copy:CalRecycle Yellow Copy:Operator Pink Cop : ■ <br />