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Waste Tire S.., Bey & Inspection Repor, Inspection Report Number <br /> CalRecycle State of California I 1 - 1-17637`� -1 7 6 3 7 <br /> CalRecycle 181(Rev.10/10) Survey Form - Page 1 l --ff <br /> Dept.of Resources Recycling and Recovery(CalRecycle) <br /> BLUE OR BLACK INK PEN <br /> Part A- Survey <br /> Business Profile Inspection Details <br /> TPID- Inspection Type(Fill one) <br /> Site Suffix: )� O g ® Routine Q Re-inspection Q Referral Q Observation <br /> LocalC J_, If Referral,choose referral type(Fill one) <br /> Identifier: � cltxk ✓1� �IJVI.I [--, Q CHP Q CalRecycle Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name Inspected By Inspector <br /> L C)y A-m c GS <br /> Physical Address <br /> CA <br /> 33 6 Inspection Date <br /> v lC�✓� ,C'-LC;� �� Time In Time Out l t <br /> Business Rep Title i O AM O AM <br /> l a ®PM & PM <br /> tc1�_'_ t► 19�- `�""�� Operational Status Tire Type Business Role Storage Type <br /> (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> Tire Count (Whole/PTE) <br /> Active ® Passenger �Generator ® Outdoor <br /> O Q Closed Q Altered <br /> GPS Latitude Q Hauler Q Indoor <br /> O Q Inactive Q Truck <br /> Longitude - Q Planned Q OTR End Use Q Container <br /> Business Type(Fill all that apply) <br /> ® New Tire Dealer Q Auto Repair Q Trucking Fleet Q Government Q Retreader Q Dismantler Q Tire Derived Fuel <br /> ® 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 Q Notice Of Violation Q Extension <br /> Q Q 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 /> 1 Q Q 14 CCR§18459-Responsible Entities Complying with Manifesting Requirements Date m I m N <br /> Q Q 14 CCR§18459.1 -Tire Program ID Number from CalRecycle <br /> Q Q 14 CCR§ - (Required for NOV or EXT) N <br /> 18459.2.1 Submittal of Comprehensive Trip Logs within 90 days <br /> Q Q 14 CCR§18459.3-Retention of Comprehensive Trip Logs for 3 years <br /> Q Q Referred/CalRecycle Enforcement <br /> 14 CCR§18460.2-Manifest System Requirements for Registered Waste Tire Haulers Q y w <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 /> �rvv►rYl C'/�_ <br /> Inspection Form Included: Q 2 _a 3�_�d �I <br /> �6 .fG7 <br /> Comments Included: <br /> Business Rep's Signature Phone Number Insp or's if nat Phone Number <br /> 62081 <br /> INSTRUCTIONS ON BACK Correct:40 Incorrect: E X A L 1 2 3 <br /> White Copy:CalRecycle Yellow Copy:Operator Pink Co :L © ■ <br /> ■ <br />