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Waste Tire SL Rey & Inspection Report inspection Report Number <br /> CalRec cle State of California — <br /> Y CalRecycle 181(Rev.10/10) Survey Form - Page 1 1 1245022 <br /> Dept.of Resources Recycling and Recovery(CalRecycle) <br /> _. BLUE OR BLACK INK PEN <br /> Part A- Surv_ey _ <br /> Business Profile Inspection Details <br /> TPID- MM Inspection Type(Fill one) <br /> Site Suffix: g l v 6 V I ® Routine Q Re-inspection Q Referral Q Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier: �� G5 v Q CHP Q CalRecycle Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name Inspected By Inspector <br /> cc-dp w Irvc �z� 3 °l - l p STT <br /> Physical A ress <br /> I os <br /> e- r_ q f Inspection Date /5 5 / 27 � / C <br /> �tV-, \ (0-wt 1 S`-3` Time In �J Time Out J <br /> Business Rep Title 1 *AM *AM <br /> C0 PM I QPM <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 /> Q Active Q Passenger Q Generrattor Q Outdoor <br /> O ® Closed Q Alter d 'v ��� <br /> GPS Latitude Alter NA-Q Hauler Q Indoor <br /> O Q Inactive Q Truck <br /> Longitude - Q Planned Q OTR Q 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 Q Auto Body Q Car Dealer Q Collection Q Crumb Rubber <br /> Q Service Station Q Hauler Q Agriculture Q Shredder 0 Other C3�� <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 /> Q Q PRC§42956-Registration/Decal in Vehicle <br /> Q Q 14 CCR§18459-Responsible Entities Complying with Manifesting Requirements Date 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 <br /> Q Q 14 CCR§18460.2-Manifest System Requirements for Registered Waste Tire Haulers Q Referred/CalRecycle Enforcement <br /> w <br /> Q Q 14 CCR§18461 -Manifest System Requirements for Waste Tire End-Use Facilities <br /> ®In Compliance-No Violations o <br /> Q Q Other:§ <br /> Comments{" ►1,, \ `—�G P�1 W15 �_QhC— <br /> S` <br /> Inspection Form Included: <br /> Comments Included: <br /> B sin Rep's Signat a Pho e u e'r Insp tor's Signature Phone Number <br /> 62081 <br /> INSTRUCTIONS ON BACK Correct:I. Incorrect: X EXAM P L E 1 2 3 <br /> White Copy:CalRecycle Yellow Copy:Operator Pink Copy:LEA <br />