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Waste Tire SL. ✓ey & Inspection Report Inspection Report Number ■ <br /> Caffiec cle State of California <br /> Y CalRecycle 181(Rev.10/10) Survey Forte - Page 1 I1 - 1178041 <br /> Dept.of Resources Recycling and Recovery(CalRecycle) <br /> Part A- Survey BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- Inspection Type(Fill one) <br /> Site Suffix: 3 et 0 1 0 Routine 0 Re-inspection 0 Referral 0 Observation <br /> LocalIf Referral,choose referral type(Fill one) <br /> Identifier: ��� �E:X vI� 6 0Vvl,(L( 0 CHP 0 CalRecycle 0 Complaint 0 Educational Visit 0 Other <br /> Business or Facility Name l Inspected By Inspector <br /> Physical Address <br /> t1\ �, ZUG�1P.1rWl+t�►'L <br /> Inspection Date 5 / e�' / I <br /> Time In Time Out <br /> Business Rep Title n 0 AM 0 AM <br /> PM Jill PM <br /> Operational Status Tire Type Business Role Storage Type <br /> Tire Count(Whole/PTE) u (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> l 0 0 Active ® Passenger ® Generator 0 Outdoor <br /> GPS Latitude .0 Closed 0 Altered 0 Hauler Indoor <br /> O 0 Inactive ® Truck <br /> Longitude - 0 Planned OTR 0 End-Use 0 Container <br /> Business Type(Fill all that apply) <br /> 0 New Tire Dealer 0 Auto Repair 0 Trucking Fleet 0 Government 0 Retreader 0 Dismantler 0 Tire Derived Fuel <br /> 0 Used Tire Dealer 0 Auto Body 0 Car Dealer 0 Collection 0 Crumb Rubber <br /> 0 Service Station 0 Hauler 0 Agriculture 0 Shredder ® Other tiZ,�►�yr1 <br /> Part B- Inspection of Waste Tire Dealer, Generator, Hauler and End-Use Facility ENFORCEMENT STATUS <br /> V A I HAULING AND MANIFEST REQUIREMENTS <br /> 0 0 - 0 Notice Of Violation 0 Extension <br /> § <br /> PRC 42951 Waste Tire Hauler Registration and Transport of Tires <br /> 0 0 PRC§42953-Contracts with Registered Waste Tire Haulers. Compliance Deadline <br /> 0 0 PRC§42956-Registration/Decal in Vehicle <br /> 0 0 14 CCR§18459-Responsible Entities Complying with Manifesting Requirements Date <br /> 0 0 14 CCR§18459.1 -Tire Program ID Number from CalRecycle <br /> 0 0 14 CCR§18459.2.1 -Submittal of Comprehensive Trip Logs within 90 days (Required for NOV or EXT) <br /> a <br /> 0 0 14 CCR§18459.3-Retention of Comprehensive Trip Logs for 3 years o <br /> 0 0 14 CCR§18460.2-Manifest System Requirements for Registered Waste Tire Haulers 0 Referred/CalRecycle Enforcement <br /> Lu <br /> Lu <br /> 0 0 14 CCR§18461 -Manifest System Requirements for Waste Tire End-Use Facilities <br /> 0 0 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators ,6 In Compliance-No Violations o <br /> 0 0 Other:§ <br /> z <br /> Comments <br /> N <br /> r <br /> Inspection Form Included: 0 <br /> Comments Included: ® / tot's S' ture Phone Number <br /> tn <br /> sep's Signature one Number <br /> INSTRUCTIONS ON BACK Correct:* Incorrect: EXAM - E 3 62081 <br /> ■ White Copy:CalRecycle Yellow Copy:Operator Pink Cop .LEA 0 <br />