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Waste Tire Survey & aispection Irbsport Inspection Report Number <br /> CalRec cle state of California <br /> Y CalRecycle 181(Rev.10/10) purvey Forrro gage 1 I1 1242165 <br /> Dept of Resources Recycling and Recovery(CalRecycle) <br /> Part-A-Survey BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- r-� Inspection Type(Fill one) <br /> Site Suffix: ` ­ J ` © 10 Routine 0 Re-inspection 0 Referral 0 Observation <br /> Local - / If Referral,choose referral type(Fill one) <br /> Identifier: �� �� CEJ v✓V[./ O CHP 0 CalRecycle Q Complaint 0 Educational Visit 0 Other <br /> Business or Facility Name ` Inspected By Inspector <br /> Physical Address <br /> Inspection Date <br /> a s 3C3H <br /> Time In Time Out <br /> Business Rep Title ®AM _ C� (&AM <br /> (jC4t$V I G�t �e`'(es iy tJ►ti� j l 0 • ]; 5 Q PM b ( 0 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 ®Passenger I® Generator e Outdoor <br /> - O i <br /> GPS Latitude 0 Closed 0 Altered 0 Hauler 0 Indoor <br /> O 0 Inactive I 0 Truck <br /> Longitude - 0 Planned 0 OTR 0 End-Use 0 Container <br /> Business Type(Fill all that apply) <br /> 0 New Tire Dealer 0 Auto Repair 0 Trucking Fleet 0 Government 0 Retreader 0 Dismantler 0 Tire Derived Fuel <br /> 0 Used Tire Dealer ® Auto Body 0 Car Dealer 0 Collection 0 Crumb Rubber <br /> 0 Service Station 0 Hauler 0 Agriculture 0 Shredder 0 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 /> 0 Notice Of Violation 0 Extension <br /> 0 0 <br /> PRC§42951 -Waste Tire Hauler Registration and Transport of Tires <br /> 0 0 PRC§42953-Contracts with Registered Waste Tire Haulers. Compliance Deadline <br /> PRC§42956-Registration/Decal in Vehicle <br /> 0 0 14 CCR§18459-Responsible Entities Complying with Manifesting Requirements Date M / m / m <br /> 0 0 14 CCR§18459.1 -Tire Program ID Number from CalRecycle <br /> 0 0 14 CCR§18459.2.1 -Submittal of Comprehensive Trip Logs within 90 days (Required for NOV or EX ) <br /> 0 0 14 CCR§18459.3-Retention of Comprehensive Trip Logs for 3 years o <br /> 0 0 14 CCR§18460.2-Manifest System Requirements for Registered Waste Tire Haulers 0 Referred/CalRecycle Enforcement <br /> 2 <br /> 0 0 14 CCR§18461 -Manifest System Requirements for Waste Tire End-Use Facilities W <br /> 0 0 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators <br /> in Compliance-No Violations o <br /> 0 0 Other:§ <br /> Comments <br /> ee L- <br /> Inspection Form Included: 0 <br /> 7 <br /> Comments Included: <br /> Business Rep's Signature Phone Number Ins a or's g ture Phone Number <br /> INSTRUCTIONS ON BACK Correct:. Incorrect: � W E X A M 1 2 3 62081 <br /> ■ White Copy:CalRecycle Yellow Copy:Operator Pink Cop .L ® ■ <br />