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Waste Tir„ & rey & Inspection Rep jrt Inspection Report Number <br /> CalRec cle State of California — <br /> Y CalRecycle 181(Rev.10/10) Survey Form - Page 1 11 1255737 <br /> Dept.of Resources Recycling and Recovery(CalRecycle) <br /> )art A- Survey BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- Inspection Type(Fill one) <br /> Site Suffix: ' -/ 3 / I® Routine Q Re-inspection Q Referral Q Observation <br /> LocalQ1 If Referral,choose referral type(Fill one) <br /> Identifier: J �Q��(Jl Y1 Q CHP Q CalRecycle Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name Inspected By Inspector <br /> Physical Address t / ��1 1�/W r � /`=f'v✓t <br /> �s s TT_ <br /> 9-1 Inspection Date <br /> I ALJ Time In Time Out <br /> Business Rep �^ Title / , O AM ��� AM <br /> QE_y�L� 1 ► `G�l�� ��� v ® PM O PM <br /> IO-f 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 /> 0 Active Q Passenger S Generator Q Outdoor <br /> O Q Closed Q Altered <br /> GPS Latitude Q Hauler 0 Indoor <br /> O Q Inactive • Truck <br /> Longitude - Q Planned Q OTR Q End-Use Q Container <br /> Business Type(Fill all that apply) <br /> 6 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 /> ® 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 /> PRC§42956-Registration/Decal in Vehicle <br /> Q Q 14 CCR§18459-Responsible Entities Complying with Manifesting Requirements Date <br /> Q Q 14 CCR§18459.1 -Tire Program ID Number from CalRecycle N <br /> Q Q 14 CCR§18459.2.1 -Submittal of Comprehensive Trip Logs within 90 days (Required for NOV or EXE N <br /> Q Q 14 CCR§18459.3-Retention of Comprehensive Trip Logs for 3 years <br /> 0 <br /> Q Q 14 CCR§18460.2-Manifest System Requirements for Registered Waste Tire Haulers Q Referred/CalRecycle Enforcement <br /> Lu <br /> Lu <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 /> w4-.1 fWAY <br /> t--)ov o LQ tt _. bar D Lug y <br /> Inspection Form Included: (2y <br /> ��Ve coq- '` i- Zoe, 4��-_ <br /> Comments IncludedByr�iness Rs' re Phone Number Inspector's Signature Phone Number <br /> // 62081 <br /> INSTRUCTIONS,: BACI Correct:0 Incorrect: E X A M P L E 1 1 2 3 <br /> ■ %White Copy:CalRecycle Yellow Copy:Operator Pink Copy:LEA ■ <br />