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Waste Tire Survey & Inspection Report Inspection Report Number <br /> CalRec cle State of California — <br /> Y CalRecycle 181(Rev.10/10) Survey Form - Page 1 1 1242296 <br /> Dept.of Resources Recycling and Recovery(CalRecycle) <br /> Part A-Survey_ BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- r7 r-1 o Inspection Type(Fill one) <br /> Site Suffix: 1 3 ` r O 6 0 Routine Q Re-inspection Q Referral Q Observation <br /> LocalIf Referral,choose referral type(Fill one) <br /> 1 � p <br /> Identifier: f�{N J iJu GI u t ^ co kk'-, Q CHP Q CalRecycle Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name 6 Inspected By Inspector <br /> Physical Address C s LO <br /> Inspection Date 2 I I / I <br /> A( 'ec C fl `►5���7 <br /> Time In Time Out <br /> Business Rep Title 1 , 0 AM 0 AM <br /> S 0 PM L4I 5 is PM <br /> i`� "1 <br /> "S R&�'1°!` Operational Status Tire Type Business Role Storage Type <br /> (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> Tire Count(Whole/PTE) s <br /> ® Active 0 Passenger ® Generator Q Outdoor <br /> O Q Closed Q Altered <br /> GPS Latitude Q Hauler ® 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 /> ® 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 * 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 Q Notice Of Violation Q Extension <br /> Q Q 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 / 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 /> a <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 /> 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:§ <br /> Comments n [A �+�-)t f` 1/�5 i�i U.. D'�R� �r �� -C',C qu <br /> p;1AJ <br /> Inspection Form Included: QZIA <br /> -(� _ <br /> Comments Included: ® �Z 3 �� GK73 1�_ <br /> Bu iness p's Signature Phone Number Inspec is Signature Phone Number <br /> 62081 <br /> INSTRUCTIONS ON BACK Correct:18 Incorrect: � 7 E X A M P L 1 2131 <br /> ■ White Copy:CalRecycle Yellow Copy:Operator Pink Copy:L <br />