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02 Waste Tire Survey & Inspection Repor L Inspection Report Number ■ <br /> CalRecycle State of California 11 - 1176770 <br /> CalRecycle 181(Rev.10/10) <br /> (Cal <br /> Dept.of Resources Recycling and Recovery(CalRecycle) Survey Form - Page 1 <br /> PartA -Surve rte _ _ - _ BLUE OR BLACK INK PEN <br /> Business Profile _ Inspection Details <br /> TPID- Inspection Type(Fill one) <br /> QSite Suffix: l (p I l '* Routine Q Re-inspection Q Referral Q Observation <br /> Local + If Referral,choose referral type(Fill one) <br /> Identifier: 0"(\7((9 coq Q CHP Q CalRecycle Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name 4(- <br /> Inspected By /, CInspector <br /> (Ic4t.1 1141 '044 aGd - 1�-p zti( 3 I - I <br /> Physical Address V ok <br /> Inspection Date <br /> Uac GA '153377 <br /> Time In Time Out <br /> Business Rep Title r 0 AM s 0 AM <br /> 1 3 b ® PM `' 4P <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) 3 <br /> I ®Active ® Passenger Generator ® Outdoor <br /> Q Closed Q Altered <br /> GPS Latitude Q Hauler ® Indoor <br /> 0 Q Inactive ® Truck <br /> Longitude - Q Planned Q OTR Q End-Use Q Container <br /> j Business Type(Fill all that apply) <br /> Q New Tire Dealer &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 <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 /> Q Q 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 3 <br /> Q Q 14 CCR§18459.2.1 -Submittal of Comprehensive Trip Logs within 90 days (Required for NOV or EX7) n <br /> I� <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 /> Uj <br /> W <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 k+fit I Q� rQ, U <br /> NQ 111�11�, IU aS G(,raUS COCI[9[n <br /> Inspection Form Included: Q <br /> Comments Included: <br /> Business Rep's Signature Phone Number �­Insp�r'�sSigture Phone Number <br /> ,- 62081 <br /> INSTRUCTIONS ON BACK Correct:4D Incorrect: _ � E X A P L 1 2 3 <br /> ■ White Copy:CalRecycle Yellow Copy:Operator Pink Cy' <br />