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Waste Tire Su, Bey & Inspection Repon Inspection Report Number <br /> CalRec cle State of California _ <br /> Y CalRecycle 181(Rev.10/10) Survey Form - Page 1 I1 1244926 <br /> Dept,of Resources Recycling and Recovery(CalRecycle) <br /> 'art A- Survey BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- i n _ © Inspection Type(Fill one) <br /> Site Suffix: b 46 Routine Q Re-inspection Q Referral Q Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier: �Gn JOUIXAI;n C(3 O CHP Q CalRecycle Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name Inspected By Inspector <br /> Physical Address <br /> ItiI " tAnsc-(\ CXR <br /> Inspection Date I � � � 5 S <br /> Time In Time Out <br /> Business Rep r Title 0 AM 0 AM <br /> � 5 5 6 PM �, a J .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 /> 0 Active ® Passenger ® Generator 0 Outdoor <br /> Q Closed O Altered <br /> GPS Latitude 0 Hauler ® Indoor <br /> 0 Q Inactive Q Truck <br /> Longitude - Q Planned O OTR O 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 ® 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 � 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 /> 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 <br /> a <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 Q Referred/CalRecycle Enforcement <br /> w <br /> O O 14 CCR§18461 -Manifest System Requirements for Waste Tire End-Use Facilities <br /> O O 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators <br /> in Compliance-No Violations o <br /> O O Other:§ <br /> Comments n ._ 1j f e. � rj o�Ol1 r�✓1�2, �'1������,`�c� G1�� �, <br /> e�41 n_ <br /> Inspection Form Included: Q <br /> + <br /> Comments Included: <br /> ,✓Business Rep's Signature Phone Number Inspec is Signature one Number <br /> G 62081 <br /> INSTRUCTIONS ON BACK I Correct:I. Incorrect: E I XI M P E 123 <br /> ■ White Copy:CalRecycle Yellow Copy:Operator Pink Cop ■ <br />