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Waste Tin 1 tey & Inspection Rea `nspection Report Number <br /> CalRecycle State of California I 1 - 1176623 <br /> CalRecycle 181(Rev.10/10)C Survey Form - Page 1 <br /> Dept.of Resources Recycling and Recovery(CalRecycle) <br /> BLUE OR BLACK INK PEN <br /> Part A- Survey <br /> Business Profile Inspection Details <br /> TPID- Inspection Type(Fill one) <br /> Site Suffix: y 3 Z ® I® Routine Q Re-inspection Q Referral Q Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier: L�,� l Q CHP Q CalRecycle Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name Inspected By Inspector <br /> E P�C Plus'*-,°( SL o f <br /> Physical Address <br /> l a Lf <br /> Inspection Date <br /> �LY cA `I L <br /> Time In Time Out <br /> Business Rep Title O AM _ O AM <br /> In o S 0 PM C.)' S O to PM <br /> CtLL ir-e c,w ��' ►°mo i - — ---- -- - ---— <br /> Operational Status Tire Type Business Role Storage Type <br /> (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> Tire Count (Whole/PTE) <br /> Q Active Q Passenger ® Generator Q Outdoor <br /> Q Closed Q Altered <br /> GPS Latitude I Q Hauler Q Indoor <br /> 0 ® Inactive Q Truck <br /> Longitude - Q Planned ® OTR Q End-Use Q Container <br /> Business Type(Fill all that apply) f <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 ® Otherwy�,�Z <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 /> V) <br /> 459.1 -Tire Program ID Number from CalRecycle <br /> m <br /> Q Q 14 CCR§18 cle g Y <br /> Q Q 14 CCR 18459. - (Required fa NOV or EXT) N <br /> § 2.1 Submittal of Comprehensive Trip Logs within 90 days v <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 /> w <br /> Q Q 14 CCR§18461 -Manifest System Requirements for Waste Tire End-Use Facilities - <br /> Q Q 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 /> Inspection Form Included: Qi �nspectorls <br /> x Comments Included: Business p's Signature one Number gnature Phone Number <br /> �, 62081 <br /> INSTRUCTIONS ON BACK Correct:* Incorrect: (, 7P NJ! E X A P E 1 2 3 <br /> White Copy:CalRecycle Yellow Copy:Operator Pink opy:LE <br />