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Waste Tire SL. Bey & Inspection Report inspection Report Number <br /> cal Recycle State of California 11 - 1196684 <br /> CalRecycle181(Rev.10/10) Survey Form - Page 1 <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 � Inspection Type(Fill one) <br /> Site Suffix: I'� 0 Routine Q Re-inspection Q Referral Q Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier �d0.gV��(� WV� Q CHP Q CalRecycle0 Complaint Q Educational Visit Q Other <br /> Business or Facility Name ` r 1 Inspected By Inspector <br /> Physical le'd C �V\\�` p� �CC VC`�� 1 _ O 1 mpj T <br /> 1 <br /> Inspection Date <br /> Time In Time Out <br /> Business Rep Title *AM 0 � AM <br /> {A�A� C- O 0 PM v 0 PM <br /> ,v,��'e' 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 Active Q Passenger (6 Generator Q Outdoor <br /> O Q Closed Q Altered ,v [k <br /> GP$ Latitude Q Hauler Q Indoor <br /> O Q Inactive Q Truck <br /> Longitude — Q Planned 0 OTR Q End-Use Q Container <br /> Business Type(Fill all that apply) pct <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 0 Other LOC« ��Isar, r <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 <br /> Ffl / 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 EXE N <br /> r <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 W <br /> Q Q 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators In Compliance-No Violations o <br /> Q 1 Q 1 Other:§ <br /> Comments <br /> ` w M <br /> Inspection Form Included: Q <br /> Comments Included. Z� - + <br /> - - - Business p's Signature Phone Number Inspector's Signature Phone Number <br /> INSTRUCTIONS ON CK Correct: Incorrect: EXAMPLE 1 2 3 62081 <br /> ■ White Copy:CalRecycle Yellow Copy:Operator Pink Copy:LFA ® ■ <br />