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Waste Tire Sup Bey & Inspection Report Inspection Report Number <br /> CalRecycle State of California q — <br /> Caycling le 181(Rev.10/10) <br /> y(Cal Survey Form v Page 1 4 l <br /> Dept.of Resources Recycling and Recovery(CalRecycle) <br /> Part A-Survey BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- I � � � � - O � 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: Ste\ S`O, n U\� � / Q CHP Q CalRecycle Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name V `/7 Inspected By Inspector <br /> Physical Address G - A © 0 N� T Q <br /> \ t'c0.0 c ^ �C�� Inspection Date / �� g / <br /> /� 7 Time In Time Out <br /> Business Rep TitleO O AM I O AM <br /> O PM F I 0 PM <br /> - C�tiint�Y� � u� O hey 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 /> O 10 Closed Q Alter d� Nl/T NIA <br /> GPS Latitude k Q Hauler Q Indoor <br /> 0 Q Inactive Q Truck <br /> Longitude - Q Planned Q OTR Q End-Use Q Container <br /> Business Type(Fill all that apply) <br /> Q New Tire Dealer 10 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 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 EXE <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 is In Compliance-No Violations o <br /> Q Q Other:§ <br /> Comments <br /> Inspection Form Included: Q _ <br /> Comments Included: o, IV-1141140-1 <br /> Business Rep's Signature Pho—r�ie�lumber Inspe r' Signature Phone Number <br /> INSTRUCTIONS ON BACK I Correct: ' Incorrect: :X� rJ E X A M P L E 1 2 3 62081 <br /> White Copy:CalRecycle Yellow Copy:Operator Pink Copy:LFA <br />