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Waste Tire Sley & Inspection Reporpinspection Report Number <br /> Stte of <br /> CalRecycle CalRecyclelifornia 181(Rev.10110) I1 - 1245017 <br /> Dept of Resources Recycling and Recovery(CalRecycle) Su rvey Form - Page 1 <br /> Part A-Survey BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- � � � � L � � � Inspection Type(Fill one) <br /> Site Suffix: 0 Routine Q Re-inspection Q Referral Q Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier: l 0.n b l� V�, Q CHP Q CalRecycle Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name Inspected By Inspector <br /> Phys ca�Address��� ���GLT�OI(� cS C �p _ O 1 <br /> Inspection Date / I 8 / 1 S <br /> 1 Time In Time Out <br /> Business Rep Title * AM 40 AM <br /> O PM Q O PM <br /> l�;c 1� �►aCrie.2 G�> ,� <br /> Operational Status Tire Type Business Role Storage Type <br /> Tire Count(Whole/PTE) 2 (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> &Active &Passenger &Generator dO Outdoor <br /> O Q Closed Q Altered <br /> GPS Latitude Q Hauler s Indoor <br /> O Q Inactive a Truck <br /> Longitude — Q Planned 0 OTR Q End-Use Q Container <br /> Business Type(Fill all that apply) <br /> Q New Tire Dealer Q Auto Repair Q Trucking Fleet 46 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 <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 /> PRC§42956-Registration/Decal in Vehicle <br /> QQ 14 CCR§18459-Responsible Entities Complying with Manifesting Requirements Date m / FT-1 / 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 EXE <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 /> 2 <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 <br /> is In Compliance-No Violations o <br /> Q Q Other:§ <br /> Comments <br /> � <br /> G <br /> �( <br /> Inspection Form Included: Q • _ <br /> Comments Included: <br /> Business Rep's Signature Phone Number Inspecto'r's Signature Phone Number <br /> 62081 <br /> INSTRUCTIONS ON BACK Correct: (Incorrect: X � g E X A M P L E 1112 3 <br /> ■ White Copy:CalRecycle Yellow Copy:Operator Pink Copy:LEA © ■ <br />