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Waste Tire S*_".-.1y & Inspection Re or�j,spection Report Number <br /> CalRec cle p p _ ■ <br /> State of California <br /> Y CalRecycle 181(Rev.10/10) �� 1�/(3� ®�m _ Page 1 117 6 4 2 7 <br /> Dept.of Resources Recycling and Recovery[CalRecycle) Survey v e BLUE ®R LACK INK PEN <br /> Part A-Survey <br /> Business Profile Inspection Details <br /> TPID- Inspection Type(Fill one) <br /> y � <br /> Site Suffix: 1 `7 i ® Routine Q Re-inspectio f eco Py Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier: c +hl4t� , t y,V� iQ CHP Q CalRecycle Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name <br /> Inspected By Inspector <br /> GLC.#'1 `. �C.:��C�T` •1_�e G�L4:2 1`.� r <br /> Physical Addresslet <br /> Inspection Date <br /> C-A )S i 'time In 'Time Out <br /> Business Rep Title � O AM _ O AM <br /> ® PM 0 ®PM <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 /> '* Active Q Passenger ® Generator ® Outdoor <br /> GPS Latitude <br /> O Q Closed Q Altered <br /> • <br /> Hauler 0 Indoor <br /> O Q Inactive Q Truck <br /> Longitude — Q Planned ® OTR Q End-Use Q Container <br /> Business Type(Fill all that apply) (,'F F <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 Q Car Dealer Q Collection Q Crumb Rubber <br /> Q Service Station Q Hauler Q Agriculture Q 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 /> Q Notice Of Violation Q Extension <br /> Q Q <br /> 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 /> 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 EX7) M1 <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 /> Q Q 14 CCR§18461 -Manifest System Requirements for Waste Tire End-Use Facilities w <br /> Q Q 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators in <br /> ®In Compliance-No Violations o <br /> Q Q Other:§ <br /> z <br /> Comments <br /> Inspection Form Included: Q <br /> Comments Included: <br /> Business Rep's fg+aawf / Phone Numbernspector's Si nature Phone Number <br /> INSTRUCTIONS ON BACK Corre Inc ect: E X A P VEJ 1.12131 62081 <br /> White Copy:C Yellow Copy:Operator Pink Clpy..i,//V_� <br />