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Waste Tire our vey & Inspection Rep Inspection Report NumberState of <br /> ■ <br /> calRecycle CalRecyclellfornia 181(Rev.10/10) _ I 1 - 1- 245173 <br /> Dept.of Resources Recycling and Recovery(CalRecycle) Survey Form Page 1 <br /> Part A-Survey BLUE OR BLACK INK PEN <br /> Business Profile inspection Details <br /> TPID- G� _ Q Inspection Type(Fill one) <br /> Site Suffix: 0 Routine Q Re-inspection Q Referral Q Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier: n TCC" l a� Q CHP Q CalRecycle Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name t( Inspected By Inspector <br /> S.5 A--- "mac nom., }��.C,e` � CN� <br /> Physical Address <br /> Inspection Date <br /> CAI` _3 <br /> Time In Time Out <br /> Business Rep Title 0 AM --7 0 AM <br /> T �,�,nk CIM!e 1 ® PM l 0 PM <br /> Yy <br /> ✓(� 'Operational Status Tire Type Business Role Storage Type <br /> Tire Counthol /PTE) (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> 6) 40 Active Q Passenger 0 Generator ® Outdoor Z_ <br /> Q Closed Q Altered <br /> GPS Latitude Q Hauler Indoor <br /> O Q Inactive 0 Truck <br /> Longitude - Q Planned 0 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 ® 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 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 iQ 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 E)C7) N <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 /> Lu <br /> W <br /> Q Q 14 CCR§18461 -Manifest System Requirements for Waste Tire End-Use Facilities <br /> Q Q 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators (&In Compliance-No Violations o <br /> Q Q Other:§ z <br /> CommentsVICA� LA MAR 7, - N <br /> Ct <br /> Inspection Form�nc <br /> ncluded: Q <br /> Comments luded: 0 <br /> _ Business Rep's Signature Phone Number Inspector's Signature Phone Number <br /> INSTRUCTIONS ON BACK Correct: Incorrect: E X A M P L E 1112 3 62081 <br /> ■ White Copy:CalRecycle Yellow Copy:Operator Pink Copy:LEA © 0 <br />