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Inspection Report Number <br /> Waste Tire S�.. Bey & Inspection Report � <br /> State of California <br /> CalRecycle I 1 - 12 3 015 5 <br /> CalRecycle 181(Rev.10/10) <br /> ry(cal Survey Form - Page 1- - <br /> Dept.of Resources Recycling and Recovery(CalRecycle) <br /> Part A- Survey BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- (y c 1 Inspection Type(Fill one) <br /> Site Suffix: 1 �1 2 5 J ! @ Routine Q Re-inspection Q Referral Q Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier: � Q CHP Q CalRecycle Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name f Inspected By Inspector <br /> Physir�A <br /> pAddress <br /> Inspection Date ® 2 1 / 4 <br /> ` tt;..CY C q53?7 <br /> Time In Time Out <br /> Business Rep Title * AM Z 0 AM <br /> 0 PM 0 PM <br /> Operational Status Tire Type Business Role Storage Type <br /> Tire Count(VI/hole/PTE) (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> Active Q Passenger !Generator Q Outdoor <br /> O Q Closed Q Altered <br /> GPS Latitude Q Hauler Q Indoor <br /> O Q Inactive 9 Truck <br /> Longitude - Q Planned Q OTR Q End-Use 0 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 /> 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 0 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 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 <br /> Q Q 14 CCR§18459.3-Retention of Comprehensive Trip Logs for 3 years <br /> Q Q 14 CCR§18460.2-Manifest System Requirements for Registered Waste Tire Haulers Q Referred/CalRecycle Enforcement :f <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 1 Q 1 Other:§ <br /> Comments -,V\e- <br /> .,n O_ O <br /> (�V L G r'r_-tt' CO'ce C"1c <br /> oAS or N C-CLs 4- 6 v\.cc(`'n <br /> Inspection Form Included: Q ' S/v) <br /> Comments Included: 82$- -f6S$ �-ZA j 68—wl -Ca <br /> Business Rep's Signature Phone Number Inspectors Signature Phone Number <br /> INSTRUCTIONS ON BACK Correct:I, Incorrect: V E X A M P L E 1112 3 62081 <br /> ■ White Copy:CalRecycle Yellow Copy:Operator Pink Copy:LEA <br />