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Waste Tire St.., vey & Inspection Report. Inspection Report NumberState of <br /> i <br /> CalRecycle CalRecy Ieiifornia 181(Rev.10/10) I1 - 1226590 <br /> Dept.of Resources Recycling and Recovery(CalRecycle) <br /> Survey Form - Page 1 <br /> Part A-Survey _- BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- ' <br /> _ O Inspection Type(Fill one) <br /> Site Suffix: 1 ( 0 Routine 0 Re-inspection 0 Referral 0 Observation <br /> Local �- t / If Referral,choose referral type(Fill one) <br /> Identifier: �CA n J 0 R 1 f) l�l� 0 CHP 0 CalRecycle 0 Complaint 0 Educational Visit 0 Other <br /> Business or Facility Name Inspected By Inspector <br /> t�r fri, (.p, New w USC T <br /> Physical ddess <br /> Cp ���ZJ� Inspection Date I 0 <br /> A <br /> Time In Time Out <br /> Business Rep Title 1 0 AM ( J O AM <br /> 1,t��- l Q PM 5 Q PM <br /> Operational Status Tire Type Business Role Storage Type <br /> Tire Count(Whole/PTE) [ O (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> ' ' J 0 Active 10 Passenger 4D Generator Is Outdoor <br /> 0 Closed 0 Altered <br /> GPS Latitude Q Hauler ® Indoor <br /> 0 0 Inactive 0 Truck <br /> Longitude - 0 Planned 0 OTR 0 End-Use 0 Container <br /> Business Type(Fill a!I <br /> ® New Tire Dealer 0 Auto PAww 0 Trucking Fleet 0 Government 0 Retreader 0 Dismantler 0 Tire Derived Fuel <br /> (S Used Tire Dealer 0 Auto Bow 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 /> 0 0 PRC§42956-Registratrcr>Decal in Vehicle <br /> 0 0 14 CCR§18459-Responsible Entities Complying with Manifesting Requirements Date <br /> M / m / m <br /> 0 0 14 CCR§18459.1 -Tire Program ID Number from CalRecycle co <br /> 0 0 14 CCR§18459.2.1 -Sit nittal of Comprehensive Trip Logs within 90 days (Required for NOV or EXT) n <br /> 0 0 14 CCR§18459.3-Reter`tion 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 /> 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 f i On4)11 n <br /> -- No t'OL, 1' ,s yr 6t <br /> Inspection Form Included: 0 <br /> Comments Included: ®- - -- --QQ <br /> iness R s Signatur Phone Nu_a(-_r Inspect 's Signature Phone Number <br /> INSTRUCTIONS ON BACK orrect:0 incorrect: EXAMPLE 1 2 3 62081 <br /> ■ White Copy:CalRecycle Yellow Copy:Operator Pink Copy:LEA © ■ <br />