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Waste Tire SlIvey & Inspection Report Inspection Report Number <br /> CaI Rec cle State of California <br /> Y CalRecycle 181(Rev.10/10) Suedorm - Page 1 I1 1245086 <br /> Dept.of Resources Recycling and Recovery(CalRecycle) <br /> Part A-Survey BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- c" ` ..Z -�, ( Inspection Type(Fill one) <br /> Site Suffix: ✓ 1 f 0 Routine 0 Re-inspection 0 Referral 0 Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier: r) jtactot vrl Ce ,,,,—^f� 0 CHP 0 CalRecycle 0 Complaint 0 Educational Visit 0 Other <br /> Business or Facility Name �� Inspected By Inspector <br /> V � <br /> Physical Address I.IV v 1 } k i/N v <br /> Inspection Date 4-- 2 <br /> Time In Time Out <br /> Business Rep TitleO AM //,, �] AM <br /> QPM � Z V 'T" O 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 /> 0 Active 0 Passenger 0 Generator O Outdoor <br /> 0 Closed 0 Altered <br /> GPS Latitude 0 Hauler 0 Indoor <br /> 0 0 Inactive ® Truck <br /> Longitude - 0 Planned OTR 0 End-Use 0 Container <br /> Business Type(Fill all that apply) <br /> 0 New Tire Dealer 0 Auto Repair 0 Trucking Fleet 0 Government 0 Retreader 0 Dismantler 0 Tire Derived Fuel <br /> 0 Used Tire Dealer 0 Auto Body 0 Car Dealer 0 Collection 0 Crumb Rubber <br /> 0 Service Station 0 Hauler 0 Agriculture 0 Shredder `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 /> 0 Notice Of Violation 0 Extension <br /> 0 0 PRC§42951 -Waste Tire Hauler Registration and Transport of Tires <br /> 0 O PRC§42953-Contracts with Registered Waste Tire Haulers. Compliance Deadline <br /> PRC§42956-Registration/Decal in Vehicle <br /> 00 14 CCR§18459-Responsible Entities Complying with Manifesting Requirements Date Ffl / M / <br /> m <br /> 0 0 14 CCR§18459.1 -Tire Program ID Number from CalRecycle <br /> 0 0 14 CCR§18459.2.1 -Submittal of Comprehensive Trip Logs within 90 days (Required for NOV or EXE <br /> 0 0 14 CCR§18459.3-Retention of Comprehensive Trip Logs for 3 years o <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 O 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators <br /> *in Compliance-No Violations o <br /> 0 O 1 Other:§ <br /> Comments "n <br /> r- wa4lc <br /> 1 11��/ I �-� � e:j. .-f•J, _ da-k a J <br /> I(oo I►'4. LLz0 {'llj Qt� '• f w✓y <br /> Inspection Form Included: 0 ` . q O <br /> Comments Included: 0— �u r'��2 _ <br /> Business Rep's Si6riature Phone Number Inspector' nature Phone Number <br /> INSTRUCTIONS ON BACK I Correct:* Incorrect: � E X A M P L E 1112 3 62081 <br /> ■ White Copy:CalRecycle Yellow Copy:Operator Pink Copy:LEA ® 0 <br />