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Waste Tire SAey & Inspection Report Inspection Report NumberState of <br /> ■ <br /> CalRecycle CalRecyclel1fornia 181(Rev.10/10) 11 <br /> Dept.of Resources Recycling and Recovery(CalRecycle) <br /> Survey Form - Page 1 1229971 <br /> Part A -Survey _ _ BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- � � � ,�, � a � _ Inspection Type(Fill one) <br /> Site Suffix: cJ� v o 0 Routine 0 Re-inspection 0 Referral 0 Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier: ��/; n �j���j� 0 CHP 0 CalRecycle 0 Complaint 0 Educational Visit 0 Other <br /> Business or Facility Name Inspected By Inspector <br /> Physica ss Q v <br /> 6'k ��S [, <br /> Q Inspection Date O Z -) / r <br /> Ski Y\ <br /> Time In Time Out <br /> Business Rep d Title 0 AM O AM <br /> po CC ��Ce. c�rC �" � I ' ' O o PM l Cs * PM <br /> Operational Status Tire Type Business Role Storage Type <br /> Tire Count (Whole/PTE) I ' !5 <br /> 3 (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> Active 0 Passenger 0 Generator 0 Outdoor <br /> O 0 Closed 0 Altered <br /> GPS Latitude 0 Hauler 40 Indoor <br /> O 0 Inactive 0 Truck <br /> Longitude - 0 Planned 0 OTR 0 End-Use 0 Container <br /> Business Type(Fill all that apply) <br /> New Tire Dealer 0 Auto Repair 0 Trucking Fleet 0 Government 0 Retreader 0 Dismantler 0 Tire Derived Fuel <br /> Used Tire Dealer 0 Auto Body 0 Car Dealer 0 Collection 0 Crumb Rubber <br /> 0 Service Station 0 Hauler 0 Agriculture 0 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 /> �Notice Of Violation 0 Extension <br /> 0 0 <br /> PRC§42951 -Waste Tire Hauler Registration and Transport of Tires <br /> 0 0 PRC§42953-Contracts with Registered Waste Tire Haulers. Compliance Deadline <br /> 0 0 PRC§42956-Registration/Decal in Vehicle <br /> 0 0 14 CCR§18459-Responsible Entities Complying with Manifesting Requirements Date Jnr�� / O IS <br /> 0 0 14 CCR§18459.1 -Tire Program ID Number from CalRecycle I N <br /> 0 0 14 CCR§18459.2.1 -Submittal of Comprehensive Trip Logs within 90 days (Required for NOV or EX7) N <br /> 0 0 14 CCR§18459.3-Retention of Comprehensive Trip Logs for 3 years <br /> 0 0 14 CCR§18460.2-Manifest System Requirements for Registered Waste Tire Haulers 0 Referred/CalRecycle Enforcement <br /> 0 0 14 CCR§18461 -Manifest System Requirements for Waste Tire End-Use Facilities w <br /> 0 0 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators 0 In Compliance-No Violations o <br /> 0 1 0 Other: <br /> Commentsr' <br /> Inspection Form Included: 0 �S <br /> Comments Included: ��� <br /> usiness Rep's Signature Phone Number Inspect is Signature Phone Number <br /> INSTRUCTIONS ON BACK Correct:* Incorrect: EXAMPLE1 1112L3] 62081 <br /> ■ White Copy:CalRecycle Yellow Copy:Operator Pink Copy:LEA © 0 <br />