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'�X •A�11t],111ii•1SYk•�iu.111:i.:.1'i:i� 1-_vasa_v-YiiiM:.�O:w'i-:i.:.'=1��1.-a11156'.'tiS\-w.'•:Sl:.iiu':ul�_JOO(\L-'.1S'�Y'•L1SS`��.ss.:�is'Y n iIUL'•�':-`.Lv".-ra',_t�.___.s__�_.ti.�.uts�ss__'�w''v`.''_____ <br /> Inspection Report Number <br /> Waste Tire vey & Inspection Report <br /> ur <br /> Cal Rec cle State of California — <br /> Y CalRecycle 181(Rev.10/10) Survey Form - Page 1 I1 1245134 <br /> Dept.of Resources Recycling and Recovery(CalRecycle) <br /> Part A-Survey BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- inspection Type(Fill one) <br /> Site Suffix: ✓ J p �(1 O ' ® Routine Q Re-inspection Q Referral Q Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier: JLKI V L yl Ccv O CHP Q CalRecycle Q Complaint O Educational Visit O Other <br /> Business or Facility Name Inspected By Inspector <br /> Physical Address <br /> '�qUo pla2 ' (vm' <br /> Time In <br /> Inspection Date C Time Out � <br /> �cLt' Ci �s.3d f i <br /> Business Rep Title � � ®AM 7 0 O Q AM <br /> QPM / 40 PM <br /> �Irwel� <br /> Operational Status Tire Type Business Role Storage Type <br /> Tire Count Qoh le/PTE) 5-10 (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> a Active ® Passenger ® Generator & Outdoor <br /> O Q Closed Q Altered <br /> GPS Latitude Q Hauler Q indoor <br /> O Q Inactive Q Truck <br /> Longitude — Q Planned Q OTR 0 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 e 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 /> V1 A I HAULING AND MANIFEST REQUIREMENTS <br /> 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 /> O Q PRC§42956-Registration/Decal in Vehicle <br /> Q 0 14 CCR§18459-Responsible Entities Complying with Manifesting Requirements Date m / m / m <br /> Q Q 14 CCR§18459.1 -Tire Program ID Number from CalRecycle <br /> Q Q 14 CCR§18459.2.1 -Submittal of Comprehensive Trip Logs within 90 days (Required for NOV or EXn <br /> O O 14 CCR§18459.3-Retention of Comprehensive Trip Logs for 3 years <br /> O O 14 CCR§18460.2-Manifest System Requirements for Registered Waste Tire Haulers Q Referred/CalRecycle Enforcement <br /> f <br /> W <br /> O O 14 CCR§18461 -Manifest System Requirements for Waste Tire End-Use Facilities <br /> O O 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators in Compliance-No Violations o <br /> O O Other:§ <br /> Comments <br /> r6i Ur ' v <br /> 2D'9 <br /> Inspection Form Included: Q �._ <br /> 7� <br /> Comments Included: . <br /> Busines p s Signature Phone Number Inspecto Signa Phone Number <br /> INSTRUCTIONS ON BA K Correct: Incorrect: EXAMPLE 1 2 3 62081 <br /> ■ ite Co Recycle Yellow Copy:Operator Pink Copy:LEA © ■ <br />