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Waste Tire SOvey & Inspection Repoi Inspection Report Number-] <br /> State of California <br /> CalRecycle 10/10)CalRecycle 181(Rev. I 1 - :1 2 4 5 3 7 5 <br /> (Cal <br /> Dept.of Resources Recycling and Recovery(CalRecycle) Survey Form - Page 1 - --- --- <br /> Part A-Survey BLUE OR BLACK INK PEN <br /> BusinessP_rofj a Inspection Details <br /> inspection f ection Type(Fill one) <br /> Site Suffix: , � - L <br /> J 06 <br /> TPID- Routine Q Re-inspection Q Referral Q Observation <br /> Local , If Referral,choose referral type(Fill one) <br /> Identifier: �- �� J Q CHP Q CalRecycle Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name Inspected By Inspector <br /> Physical Address <br /> L-3Zz3 - �1��'rnrnl�t� r, � -Ls ] <br /> s:,r:et975,2Z� Inspection Date � T / t <br /> ) c't�U� (f State ` 7!P Code Time In 0 AM J Time Out <br /> OAM <br /> Business Rep � Titley I � Z (� � ® PM � ���� 0 PM <br /> I�;t.✓x , �.lc�uf�5 ..�c. yin- --�-- --� ' -- <br /> 'Operational Status Tire Type Business Role Storage Type <br /> Tire Count hol PTE) Q (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> ® Active 0 Passenger to Generator Q Outdoor <br /> Q Closed Q Altered <br /> GPS Latitude Q Hauler ® Indoor <br /> O Q Inactive Q Truck j <br /> Longitude - Q Planned Q OTR Q End-Use Q Container <br /> I <br /> Business Type(Fill all that apply) <br /> 0 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 Q Other i <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 /> QQ 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 <br /> Q Q 14 CCR§18459.2.1 -Submittal of Comprehensive Trip Logs within 90 days (Required for NOV or EX7) N <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 /> LU <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 Q Other:§ i <br /> Comments i ou_-tu� ( K.,m Ot.t.C� Gee CVL_'74w4a dab <br /> — <br /> 44." 'P6 11C ou" <br /> D <br /> Inspection Form Included: Q <br /> Comments lncluded:'(1� <br /> Business Rep's Signature Phone Number spector's Signature Phone Number <br /> 62081 <br /> INSTRUCTIONS ON BACK FCorrect: Incorrect: E X A M P L E 1112 3 <br /> ■ White Copy:CalRecycle Yellow Copy:Operator Pink Copy:LEA <br />