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Waste Tire ui vey & Inspection Reps. t•Inspection Report Number <br /> q <br /> CalRecycle State of California _ ■ <br /> CalRecycle 181(Rev.10/10) <br /> ry(Ca[ Survey Form Page 1 I1 1245398 <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 7 /� Z - c-) / Inspection Type(Fill one) <br /> Site Suffix: L- `) 0 Routine Q Re-inspection Q Referral Q Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier: V-) { Q CHP Q CalRecycle Q Complaint Q Educational Visit Q Other <br /> BusinessorFacility Name Inspected By � InspectoSar <br /> desss ( t,(LOS <br /> J C <br /> Physical A � - v <br /> �f 2- McU ,Sf iz e.uJ- <br /> Inspection Date <br /> Time In Time Out <br /> Business Rep Title 0 AM 0 AM <br /> O PM 3 � Sre PM <br /> Operational Status Tire Type Business Role Storage Type <br /> �; •� Q <br /> Tire Count le/PTE) (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> IS Active 0 Passenger 0 Generator 0 Outdoor <br /> Q Closed Q Altered <br /> GPS Latitude ® 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 Q Auto Repair Q Trucking Fleet Q Government Q Retreader Q Dismantler Q Tire Derived Fuel <br /> 0 Used Tire Dealer Q Auto Body Q Car Dealer Q Collection Q Crumb Rubber <br /> Q Service Station 0 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 In <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 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 0 In Compliance-No Violations o <br /> Q Q 1 Other:§ <br /> Comments <br /> � <br /> �"7 k, cu; yl 6r-4 <br /> oY �w <br /> Inspection Form Included: Q <br /> Comments Included:• <br /> Business Rep's Signature Phone Number Inspector's Signature Phone Number <br /> INSTRUCTIONS ON BACK Correct:0 Incorrect: E�XJAJMJP � LJEJ 1112 3 62081 <br /> ■ White Copy:CalRecycle Yellow Copy:Operator Pink Copy:LEA © 0 <br />