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Waste Tire 6urvey & Inspection Repik Inspection Report Number <br /> CalRecycle <br /> p <br /> State of California <br /> Y CalRecycle 181(Rev.10/10) purvey F® � m page 1 1 - 12 4 5116 <br /> Dept.of Resources Recycling and Recovery(CalRecycle) <br /> Part A-Survey BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- ) � / b- - � i Inspection Type(Fill one) <br /> Site Suffix: f 6 (� J ® Routine Q Re-inspection Q Referral Q Observation <br /> LocalIf Referral,choose referral type(Fill one) <br /> Identifier: --a0a 0 �Y.) QL/24 Q CHP Q CalRecycle Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name Inspected By Inspector <br /> Physical Address <br /> Z`'1(o� rn v ham L <br /> 9 Inspection DateC4 jz3v, <br /> Time In Time Out <br /> Business Rep Title 411 AM } r, �; ® AM <br /> Bi O PM I (� (� O PM <br /> Operational Status Tire Type Business Role Storage Type <br /> Tire Count6ho /PTE) •�, (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> Tire Count )/PTE) <br /> 4 Active . Passenger a Generator Q Outdoor <br /> Q Closed Q Altered <br /> GPS Latitude Q Hauler 0 Indoor <br /> 0 Q Inactive ®Truck <br /> Longitude — Q Planned OTR Q End-Use Q Container <br /> Business Type(Fill all that apply) <br /> Q New Tire Dealer Q Auto Repair Q Trucking Fleet • 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 /> 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 /> PRC§42956-Registration/Decal in Vehicle <br /> Q Q 14 CCR§18459-Responsible Entities Complying with Manifesting Requirements Date 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 E)CT) 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 /> 2E <br /> Q Q 14 CCR§18461 -Manifest System Requirements for Waste Tire End-Use Facilities W <br /> Q O 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators ®In Compliance-No Violations o <br /> Q Q Other:§ <br /> Comments ` <br /> 44 <br /> Inspection Form Included: Q <br /> Comments Included: — C <br /> usiness Rep'signature Phone Numbe Inspector's Signature Phone Number <br /> INSTRUCTIONS ON BACK I Correct:1@1Incorrect: X ( E X A M P L E 1 2 3 62081 <br /> ■ White Copy:CalRecycle Yellow Copy:Operator Pink Copy:LEA ® ■ <br />