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Oa Waste Tire Survey & Inspection Report Inspection Repc(t Number <br /> CalRecycle State of California I5�1 I 1 ® 1245308 <br /> CalRecycle 181(Rev.10/10) CI Ii i/®� �oEP f fil Page 1 <br /> Dept.of Resources Recycling and Recovery(CalRecycle) V M r Y e Form <br /> �9 Page <br /> Part A-Survey BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- Inspection Type(Fill one) <br /> Site Suffix: 2 S 1 • Routine Q Re-inspection Q Referral Q Observation <br /> Local / If Referral,choose referral type(Fill one) <br /> Identifier: (��� U t� V Q CHP Q CalRecycle Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name vvv Inspected By Inspector <br /> Physic ddr - LJ l A "! ! v <br /> Inspection Date J S / S <br /> � <br /> e A Z4 (� <br /> "�� � � Time In Time Out <br /> Business Rep Title O AM O AM <br /> 0 PM 0 PM <br /> �J - �1 ��� �✓ 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 /> o Active Q Passenger S Generator * Outdoor <br /> O Q Closed Q Altered <br /> GPS Latitude Q Hauler Q Indoor <br /> O Q Inactive ! Truck <br /> Longitude - Q End-Use Q Container <br /> Q Planned Q OTR <br /> Business Type(Fill all that apply) <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 4P 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 <br /> Q Q 14 CCR§18459.1 -Tire Program ID Number from CalRecycle <br /> Q O 14 CCR§18459.2.1 -Submittal of Comprehensive Trip Logs within 90 days (Required for NOV or EXT) N <br /> _ a <br /> Q Q 14 CCR§18459.3-Retention of Comprehensive Trip Logs for 3 years <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 & 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators Wn Compliance-No Violations o <br /> Q 1 Q 1 Other:§ <br /> Comments .4e_ LoV\P 6 VN A7 .i' <br /> C-5 14A lllrl�t VA6 <br /> Inspection Form Included: QIle— <br /> Comments Included: Ah 069-;314d" <br /> Busine Rep's Signature Phone Number I specto Signature Phone Number 4 1 <br /> __]jjjjjjj <br /> INSTRUCTIONS ON BACK Correct:0 Incorrect: �7* V <br /> EXAMPLE 1 2 3 62081 <br /> ■ White Copy:CalRecycle Yellow Copy:Operator Pink Copy:LFA <br />