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Waste Tire Su. Bey & Inspection Report Inspection Report Number <br /> CalRec cle State of California - 1230394 Y CalRecycle 181(Rev.10/10) Sureoey Form - Page 1 I1 12 3 0 3 9 4 <br /> Dept.of Resources Recycling and Recovery(CalRecycle) <br /> Part A-Survey E <br /> BLUE OR BLACK <br /> Business Profile Inspection ection Detal s � <br /> TPID- I 1 C Inspection Type(Fill one) <br /> _ © ` <br /> Site Suffix: J 1 ® Routine Q Re-inspection Q Referral Q Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier: S 'Q Q �3\ Co y Q CHP Q CalRecycle Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name Inspected By Inspector <br /> Physical Address 1 ` V � <br /> d��A` ���� Inspection Date t 0 / 2 <br /> °A f'kec Time In Time Out <br /> Business Rep Title ` A AM 1 0 AM <br /> 1 0 . 2 0 PM I I ' � 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 /> ' 1] Active 0 Passenger 0 Generator Q Outdoor <br /> O Q Closed 0 Altered Aj <br /> GPS Latitude Q Hauler Q Indoor <br /> O Q inactive Q Truck <br /> Longitude - Q Planned OTR 0 End-Use Q Container <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 Q Other <br /> Part B- Inspection of Waste Tire Dealer, Generator, Hauler and End-Use Facility ENFORCEMENT STATUS <br /> V A I 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 m / m / m <br /> Q Q 14 CCR§18459.1 -Tire Program ID Number from CalRecycle <br /> Q 0 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 o <br /> Q Q 14 CCR§18460.2-Manifest System Requirements for Registered Waste Tire Haulers Q Referred/CalRecycle Enforcement <br /> LU <br /> W <br /> Q 0 14 CCR§18461 -Manifest System Requirements for Waste Tire End-Use Facilities <br /> Q 0 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators ®In Compliance- No Violations o <br /> Q Q Other:§ <br /> - a <br /> - - = <br /> Comments '�� �� 2c��.�,� <br /> N <br /> Inspection Form Included: 0 "a A411 A 3 <br /> Comments Included: 1 �V <br /> Bu mess ep's g Ature Phone Number Inspector's Signature Phone Number <br /> INSTRUCTIONS ON BACK I Correct:0 Incorrect: IEIXIAIMIPILIEI 1112 3 62081 <br /> ■ White Copy:CalRecycle Yellow Copy:Operator Pink Copy:LEA ® ■ <br />