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Waste Tire Survey & Inspection Report Inspection Report Number <br /> CalRecycle Stare of California 11 - 1245357 <br /> CalRecycle 181(Rev.10/10) Survey Form - Page 1 <br /> Dept.of Resources Recycling and Recovery(CalRecycle) BLUE OR BLACK INK PEN <br /> Part A-Survey <br /> Business Profile Inspection Details <br /> TPID- j ���-� � �_ c'�i � _ � Inspection Type(Fill one)P Q <br /> Site Suffix: l_J L ( Routine Re-inspection Referral Q Observation <br /> Local G� i If Referral,choose referral type(Fill one) <br /> Identifier: �il�� � �1��`n ��/l tl v`1\ Q CHP Q CalRecycle Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name t Inspected By Inspector <br /> -Ty Lrcc <br /> Physical Address <br /> Inspection Date / 2 Z / 5— <br /> Time In Time Out <br /> Business Rep Title ZO PM O AM <br /> G 1® PM <br /> Operational Status Tire Type Business Role Storage Type <br /> h <br /> Tire Count(6 (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> he/PTE) j 3 <br /> Active Passenger Generator 0 Outdoor <br /> Q Closed Q Altered <br /> GPS Latitude Q Hauler Q Indoor <br /> O Q Inactive 0 Truck <br /> Longitude - Q Planned Q OTR O End-Use Q Container <br /> Business Type(Fill all that apply) <br /> New Tire Dealer 0 Auto Repair Q Trucking Fleet Q Government Q Retreader Q Dismantler Q Tire Derived Fuel <br /> 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 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 m <br /> Q Q 14CCR§18459.1 -Tire Program ID Number from CalRecycle <br /> (Required for NOV or EXT <br /> Q Q N <br /> 14CCR§18459.2.1 -Submittal of Comprehensive Trip Logs within 90 days <br /> Q Q 14 CCR§18459.3-Retention of Comprehensive Trip Logs for 3 years <br /> Q Q Q Referred/CalRecycle Enforcement <br /> 14 CCR§18460.2-Manifest System Requirements for Registered Waste Tire Haulers LU <br /> W <br /> Q Q %'9CR§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 1 Q Other:§ <br /> Comments {Loin rV4 wZC/Ytd t.(1 1AA <br /> Viotatwv--Z' 6y <br /> Inspection Form Included: Q _J1(_J9_ <br /> _j. <br /> Comments Included: 0 <br /> Osiness Rep's Signature Phone Number Inspector's Signature Phone Number <br /> ,-,( 62081 <br /> INSTRUCTIONS ON BACK [C®rr�e�ct.* �Incorr�ect � 9 E X A M P L E 1 2 3 ■ <br /> ■ White Copy:CalRecycle Yellow Copy:Operator Pink Copy:LFA <br />