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02 Waste Tire Stey & Inspection Reportonspection Report Number <br /> State of California <br /> CalRecycle - 1245258 CalRecycle 181(Rev.10/10) Survey Form - Page 1 I1 12 4 5 2 5 8 <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 Type(Fill one) <br /> Site Suffix: I 2, S 6 2 6 &Routine Q Re-inspection Q Referral Q Observation <br /> Local n If Referral,choose referral type(Fill one) <br /> Identifier: 50.h J 0QY'\ �v Q CHP Q CalRecycle Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name L, Inspected By Inspector <br /> Cos" Trp-- �-e��e c' - I a 1 �' v <br /> Physical Address <br /> 50 <br /> Inspection Date <br /> l� 4_t.�/ <br /> r Time In Time Out <br /> Business Rep 1 Title O AM 1 O AM <br /> ��1 1ry(� - 1 2 : � 5 O PM l ®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 /> 0 Active 40 Passenger ® Generator Q Outdoor <br /> O Q Closed Q Altered <br /> GPS Latitude Q Hauler 10 Indoor <br /> O Q Inactive Q Truck <br /> Longitude – Q Planned Q OTR 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 /> 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 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 / 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 EX7) <br /> Q Q 14 CCR§18459.3-Retention of Comprehensive Trip Logs for 3 years <br /> 0 <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 In Compliance-No Violations o <br /> Q Q Other:§ c <br /> Comments �iL&tG4 A ��;r.� P!C�__t, Am V1 Q ^ ►ni 5 <br /> �s� h <br /> Inspection Form Included: Q00, <br /> Comments Included: —a 1A�In ' – f �l ��`��� � <br /> Bu Signature Phone Number Inspector's Signature Phone Number <br /> INSTRUCTIONS ON BACK Correct: Incorrect: 62081 <br /> E X A M P L E 1 2 3 <br /> White Copy:CalRecycle Yellow Copy:Operator Pink Copy:LEA <br />