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W <br /> 'I-* <br /> Waste Tir11S e & Inspection Relirt Inspection Report Number <br /> CalRec cle State of California Y _ <br /> Y CalRecycle 181(Rev.10/10) I1 1245174 <br /> Dept.of Resources Recycling and Recovery(CalRecycle) Survey Form - Page 1 <br /> part A-Survey BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- � � h � Z >^ � � � � Inspection Type(Fill one) <br /> Site Suffix: (� J lV @ Routine 0 Re-inspection 0 Referral 0 Observation <br /> Local �`-- If Referral,choose referral type(Fill one) <br /> Identifier: rUta <br /> u� e 0 CHP 0 CalRecycle 0 Complaint 0 Educational Visit 0 Other <br /> Business or Facility Name Inspected By Inspector <br /> ree.c CG1�t'S-(y yr -Is�v 1 C, <br /> Physical Address <br /> U so 5 - /f?_i-La <br /> Inspection Date <br /> Tyup.L� Cam CA `��Z3/ <br /> Time In Time Out <br /> Business Rep Title O AM O AM <br /> � I�"CC 0 PM � v � ® PM� ► I� <br /> 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 0 Generator 0 Outdoor <br /> O 0 Closed 0 Altered <br /> GPS Latitude 0 Hauler & Indoor <br /> O 0 Inactive ID Truck <br /> Longitude - 0 Planned 0 OTR 0 End-Use 0 Container <br /> Business Type(Fill all that apply) <br /> 0 New Tire Dealer 0 Auto Repair 0 Trucking Fleet 0 Government 0 Retreader 0 Dismantler 0 Tire Derived Fuel <br /> 0 Used Tire Dealer 0 Auto Body 0 Car Dealer 0 Collection 0 Crumb Rubber <br /> 0 Service Station 0 Hauler 0 Agriculture 0 Shredder ® Other <br /> Part B - Inspection of Waste Tire Dealer, Generator, Hauler and End-Use Facility ENFORCEMENT STATUS`7/ <br /> V A HAULING AND MANIFEST REQUIREMENTS <br /> 0 Notice Of Violation 0 Extension <br /> O 0 <br /> PRC§42951 -Waste Tire Hauler Registration and Transport of Tires <br /> 0 0 PRC§42953-Contracts with Registered Waste Tire Haulers. Compliance Deadline <br /> PRC§42956-Registration/Decal in Vehicle <br /> 0 0 14 CCR§18459-Responsible Entities Complying with Manifesting Requirements Date m / m / M <br /> 0 0 14 CCR§18459.1 -Tire Program ID Number from CalRecycle <br /> 0 0 14 CCR§18459.2.1 -Submittal of Comprehensive Trip Logs within 90 days (Required for NOV or EXEC? <br /> 0 0 14 CCR§18459.3-Retention of Comprehensive Trip Logs for 3 years <br /> 0 0 14 CCR§18460.2-Manifest System Requirements for Registered Waste Tire Haulers 0 Referred/CalRecycle Enforcement <br /> w <br /> 0 0 14 CCR§18461 -Manifest System Requirements for Waste Tire End-Use Facilities <br /> 0 0 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators •In Compliance-No Violations o <br /> 0 0 Other:§ _ <br /> Comments 1 0 <br /> Ln VDI <br /> Inspection Form Included: I <br /> Comments Included:0 — <br /> _ B es <br /> s ReOec <br /> Phone Number Inspector's Signature - - Phone Number <br /> INSTRUCTIONS ON BACK Incorrect: � � NJ E X A M P L E 11 2 1 3 62081 <br /> White Copy:CalRecycle Yellow Copy:Operator Pink Copy:LEA �� <br />