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Waste Tire 61- key & Inspection R epo�Inspection Report Number <br /> State of Clifornia <br /> ® p <br /> CalRecycle CalRecyclae181(Rev.10/10) — <br /> Dept.of Resources Recycling and Recovery(CalRecycle) <br /> Survey Form - Page 1 I1 1226672 <br /> Part A- Survey BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- h (r� / O ' Inspection Type(Fill one) <br /> Site Suffix: L <br /> ® Routine Q Re-inspection Q Referral Q Observation <br /> Local r If Referral,choose referral type(Fill one) <br /> Identifier: S G n (J �e I� M � L� Q CHP Q CalRecycle Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name J Inspected By Inspector <br /> Physical Address J , 4 W 1 -0 <br /> q0�� <br /> c � Inspection Date <br /> .�\ Ovn (,� I <br /> Time In Time Out <br /> Business Re OAM <br /> "p ' I Title 1 3 Q � PM � I AM � ® 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 /> ® Active Q Passenger ® Generator Q Outdoor <br /> D Q Closed Q Altered A <br /> GPS Latitude NQ Hauler Q Indoor <br /> O 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 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 1 - <br /> Q Service Station Q Hauler Q Agriculture Q Shredder ® Other �� ff UlI�P� <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 Q PRC§42951 -Waste Tire Hauler Registration and Transport of Tires Q Notice Of Violation Q Extension <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 <br /> 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) N <br /> 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 /> Q Q 14 CCR§18461 -Manifest System Requirements for Waste Tire End-Use Facilities w <br /> Q Q 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators ®In Compliance-No Violations <br /> Q Q Other:§ <br /> Comments \ i ► z <br /> Inspection Form Included: Q <br /> Comments Included: ® �Busines �s <br /> Sign a Phone Number Inspee Phone Number <br /> INSTRUCTIONS ON BACK Correct:® Incorrect: X A M L 1112 3 62081 <br /> ■ White Copy:CalRecycle Yellow Copy:Operator Pink Cop A <br />