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Oa Waste Tire ey & Inspection Repor nspection Report Number <br /> CalRecycle State of California 11 -117 6 6 1 <br /> CalRecycle 181(Rev.10/1 0)y(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- 1 :krr Inspection Type(Fill one) <br /> 3 <br /> Site Suffix: 1 3 b 4 © t ® Routine Q Re-inspection Q Referral Q Observation <br /> LocalIf Referral,choose referral type(Fill one) <br /> �"'--_ --J <br /> Identifier: ,1,1 � vt 0 CHP Q CalRecycle Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name Inspected By Inspector <br /> Physical Address , 3 1, - L O <br /> C'f, <br /> Inspection Date <br /> Time In Time Out <br /> Business Rep Titley AM j AM <br /> Q PM / O QPM <br /> c ` I <br /> - 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 /> S ® Active O Passenger ® Generator Q Outdoor <br /> O <br /> GPS Latitude O Closed O Altered <br /> 0 Hauler 0 Indoor <br /> O Q Inactive ® Truck <br /> Longitude - Q Planned 0 OTR Q End-Use Q Container <br /> Business Type(Fill all that apply) <br /> Q New Tire Dealer Q Auto Repair ® 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 /> - - -- ..... - <br /> V A HAULING AND MANIFEST REQUIREMENTS <br /> O Notice Of Violation O Extension <br /> O O 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 0 PRC§42956-Registration/Decal in Vehicle <br /> O 0 14 CCR§18459-Responsible Entities Complying with Manifesting Requirements Date M / Ffl / <br /> m <br /> Q Q 14 CCR§18459.1 -Tire Program ID Number from CalRecycle N <br /> O Q 14 CCR§18459.2.1 -Submittal of Comprehensive Trip Logs within 90 days (Required for NOV or EX) <br /> n <br /> Q Q 14 CCR§18459.3-Retention of Comprehensive Trip Logs for 3 years o <br /> O O 14 CCR§18460.2-Manifest System Requirements for Registered Waste Tire Haulers O Referred/CalRecycle Enforcement <br /> O O 14 CCR§18461 -Manifest System Requirements for Waste Tire End-Use Facilities W <br /> O O 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators <br /> ®In Compliance-No Violations o <br /> Other:§ <br /> Comments <br /> IA-ldf f221c4 : - <br /> Inspection Form Included: O C <br /> Comments Included: ® v ``� <br /> �_- Business Rep's Signature Phone Number Inspector's Signature Phone Number <br /> INSTRUCTIONS ON BACK Correct:41 Incorrect" E X A L 112 3 62081 <br /> White Copy:CalRecycle Yellow Copy:Operator Pink Co : <br />