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Waste Tire SL. Bey & Inspection Report Inspection Report Number . <br /> Cal Rec cle State of California <br /> Y CalRecycle 181(Rev.10/10) Survey Form - Page 1 I1 -1176775 <br /> Dept.of Resources Recycling and Recovery(calRecycle) <br /> Part A- Survey _ — ___ -- BLUE OR BL_A_CK_ INK PEN__ <br /> Business Profile Inspection Details <br /> TPID- ' D O - I Inspection Type(Fill one) <br /> Site Suffix: IS Routine Q Re-inspection Q Referral Q Observation <br /> Local "'�1 (. If Referral,choose referral type(Fill one) <br /> Identifier: S Q n V� 1.(i1 fl �VUr�1 1� Q CHP Q CalRecycle Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name 1 Inspected By Inspector <br /> ` <br /> Physical Address <br /> 1q1�S LXln110 <br /> ,1 5 3 3Q Inspection Date <br /> vl Time In Time Out <br /> Business Rep Title J r S ® AM 1 I S ® AM <br /> 1 Q PM O PM <br /> -- <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 Q Passenger ®Generator (S Outdoor <br /> D Q Closed Q Altered <br /> GPS Latitude Q Hauler Q Indoor <br /> 0 Q Inactive ® Truck <br /> Longitude - Q Planned Q OTR Q End-Use Q Container <br /> Business Type(Fill all that ap)ly) <br /> Q New Tire Dealer Q Auto Repair • Trucking Fleet Q 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 ® Other U)nClic, R\Latlk7qJL410_r <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 Q PR -- Q Notice Of Violation Q Extension <br /> C§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 /> Q Q 14 CCR§18459-Responsible Entities Complying with Manifesting Requirements Date m / m / 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 EXT) N <br /> Q 0 14 CCR§18459.3-Retention of Comprehensive Trip Logs for 3 years <br /> Q Q 14 CCR§18460.2-Manifest System Requirements for Registered Waste Tire Haulers Q Referred/CalRecycle Enforcement <br /> Q Q 14 CCR§18461 -Manifest System Requirements for Waste Tire End-Use Facilities W <br /> Q 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators ®In Compliance-No Violations o <br /> Q Other:§ <br /> Comments D N <br /> VBACCor�rect: <br /> ction Form Includeomments Included: ® Bure Phone Number Inspe or's Signatur hone Number <br /> INSTRUCTIONS ON incorrect: ` E X A M P 1 2 3 62081 <br /> White Copy:CalRecycle Yellow Copy:Operator Pink Copy. © ■ <br />