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Waste Tire Ovey & Inspection Re oo Inspection Report Number <br /> CalRecycle State of California <br /> CalRecycle181(Rev.10/10) Survey Form - Page 1 I1 - 1255806 <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 <br /> - Inspection Type(Fill one) <br /> Site Suffix: r • Routine O Re-inspection O Referral O Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier: �r ��J�� O CHP O CalRecycle O Complaint O Educational Visit O Other <br /> Business or Facility Name Inspected By Inspector <br /> Physical Address C 0 <br /> &2-(-1 l t>ka-i- La_ , =Ff S <br /> Inspection Date ' ( 3 / 1 <br /> Time In Time Out <br /> Business RepTitle O AM O AM <br /> QQ <br /> N�(X�VLC.� <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 ail that apply) <br /> • Active 0 Passenger • Generator O Outdoor <br /> Latitude O O Closed O Altered Mir <br /> GPS O Hauler O Indoor <br /> 0 O Inactive O Truck <br /> Longitude - O Planned O OTR O End-Use O Container <br /> Business Type(Fill all that apply) <br /> e New Tire Dealer 0 Auto Repair O Trucking Fleet O Government O Retreader O Dismantler O Tire Derived Fuel <br /> O Used Tire Dealer O Auto Body O Car Dealer O Collection O Crumb Rubber <br /> O Service Station O Hauler O Agriculture O Shredder O 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 /> O Notice Of Violation O Extension <br /> O O <br /> PRC§42951 -Waste Tire Hauler Registration and Transport of Tires <br /> O O PRC§42953-Contracts with Registered Waste Tire Haulers. Compliance Deadline <br /> O O PRC§42956-Registration/Decal in Vehicle <br /> O O 14 CCR§18459-Responsible Entities Complying with Manifesting Requirements Date m / m / m <br /> O O 14 CCR§18459.1 -Tire Program ID Number from CalRecycle <br /> O O 14 CCR§18459.2.1 -Submittal of Comprehensive Trip Logs within 90 days (Required for NOV or EXE N <br /> O O 14 CCR§18459.3-Retention of Comprehensive Trip Logs for 3 years o <br /> O O 14 CCR§18460.2-Manifest System Requirements for Registered Waste Tire Haulers O Referred/CalRecycle Enforcement <br /> O O 14 CCR§18461 -Manifest System Requirements for Waste Tire End-Use Facilities W <br /> O O 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators In Compliance-No Violations <br /> O 1 O 1 Other:§ <br /> Comments <br /> ►L,'1 ,tf:v-✓1 C4 U--, C-VL4!(,yJ <br /> N UY w vt, <br /> Inspection Form Included: O <br /> Comments Included: * <br /> Business ep' ignature Phone Number Inspec is Signature Phone Number <br /> INSTRUCTIONS ON BACK Correct: Incorrect: E X A M P L 62081 E 1 2 3 <br /> White Copy:CalRecycle Yellow Copy:Operator Pink Copy:LEA <br />