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Waste Tire S ley & Inspection Repor Inspection Report Number <br /> State of California <br /> CalRecycle 11 - 1255860 <br /> CalRecycle 181(Rev.10/10) <br /> (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- Inspection Inspection Type(Fill one) <br /> Site Suffix: 0 Routine Q Re-inspection Q Referral Q Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier 0.Y - � CHP 0CalRecycle 0 Complaint QEducational Visit QOther <br /> Business or Facility Name VE <br /> Inspected By Inspector <br /> Physical Address <br /> -76-7 5- C l,z r-oUz-r— <br /> C� Sze o <br /> l " � <br /> Inspection Date O 7 <br /> � <br /> Time In Time Out <br /> Business Rep Titllee� O AM C O AM <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 /> Q Active Q Passenger Q Generator Q Outcl <br /> O 0 Closed Q Alt re P JA- "`ill// <br /> GPS Latitude Q Hauler Q Indoor <br /> 0 Q Inactive Q Truc <br /> Longitude - Q Planned Q OTR I Q End-Use Q Container <br /> Business Type(Fill all that apply) <br /> New Tire Dealer Q Auto Repair Q Trucking Fleet Q Government Q Retreader Q Dismantler Q Tire Derived Fuel <br /> 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 /> V A HAULING AND MANIFEST REQUIREMENTS <br /> Q 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 /> Q Q PRC§42956-Registration/Decal in Vehicle <br /> Q Q 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 EXE N <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 /> f <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 Compliance- No Violations <br /> Q Q Other:§ <br /> Comments <br /> Nom'- L1 s ALL. MD___VS�-7 y 6 3 --b). c,l; v� <br /> --y.,s -tmv .� rhos_ U) zsS9711�, <br /> Inspection Form Included: Q L <br /> Comments IncludedQ <br /> B siness Rep's Signature PNumber Inspe or s Signature Phone Number <br /> B/siness Rep's Signature <br /> INSTRUCTIONS ON BACK ncorrect: EXAMPLE 1 2 3 62081 <br /> White Co , IRecyc Yellow Copy:Operator Pink Copy:LEA <br />