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Waste Tire Suivey & Inspection Report Inspection Report Number <br /> cal6ecycle State of California I 1 - 1226616 <br /> CalRecycle 181(Rev.10/10) Survey Form - Page 1 <br /> Dept.of Resources Recycling and Recovery(CalRecycle) <br /> BLUE OR BLACK INK PEN <br /> Part A-Survey <br /> Business Profile Inspection Details <br /> TPID- Inspection Type(Fill one) <br /> Site Suffix: �(� 6 y a a Routine Q Re-inspection Q Referral Q Observation <br /> Locald CCLN, If Referral,choose referral type(Fill one) <br /> Identifier: �'��y1 Q CHP Q CalRecycle Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name Inspected By Inspector <br /> Physical Address 3 <br /> �. � <br /> " Inspection Date <br /> �} <br /> ' CA p C-4, CA CI �`3-7 Time In Time Out <br /> Business Rep Title AM &AM <br /> d 0 P Z QPM <br /> Ran %C_AsCV,,_ t�e.�t 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) 9 3 (� �� <br /> ® Active ® Passenger ® Generator Q Outdoor <br /> O Q Closed Q Altered <br /> GPS Latitude i Q Hauler & Indoor <br /> O Q Inactive 0 Truck 10 <br /> Longitude - Q Planned ® OTR End-Use (� Container <br /> Business Type(Fill all that apply) <br /> IINew Tire Dealer ® Auto Repair Q Trucking Fleet Q Government Q Retreader Q Dismantler Q Tire Derived Fuel <br /> ® Used Tire Dealer Q 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 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 <br /> Q Q 14 CCR§18459.1 -Tire Program ID Number from CalRecycle a <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 o <br /> Q O 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 /> Q Q 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators 0?In Compliance-No Violations o <br /> Q Q Other:§ z <br /> Comments <br /> r ^ <br /> Inspection Form Included: <br /> Comments Included: �4ui Pha <br /> s Rep's Signature a Number n tor' ig tur one Number <br /> 62081 <br /> INSTRUCTIONS ON BACK Correct:0 Incorrect: ® � E X A M 1 213 <br /> 0 White Copy:CalRecycle Yellow Copy:Operator Pink Copy: E © ■ <br />