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03 Waste Tire Avey & Inspection Repor ,, Inspection Report Number <br /> Cal Rec cle State of California — <br /> Y CalRecycle 181(Rev.10/10) I1 12 5 5 916 <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- J! .-- Z ' ~� Inspection Type(Fill one) <br /> Site Suffix: ✓ S J - V 1 Q Routine Q Re-inspection Q Referral Q Observation <br /> LocalIf Referral,choose referral type(Fill one) <br /> Identifier: <br /> -Too-go�� ��� Q CHP Q CalRecycle Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name Inspected By Inspector <br /> Physical Address / ) I . , L)Wyyf L /C 17� <br /> v Inspection Date / / S� <br /> Lct>H&-v C�4 rS330 1 Z c� 1 <br /> Time In Time Out <br /> Business Rep Title ^ l O AM 0 AM <br /> �r�r��(� V utl� _ � c71� 1 � e PM � � � ® PM <br /> S 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 /> a Active S Passenger 0 Generator 0 Outdoor' <br /> Q Closed Q Altered <br /> GPS Latitude Q Hauler Q Indoor <br /> O Q Inactive ® Truck <br /> Longitude - Q Planned • 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 PRC§42951 -Waste Tire Hauler Registration and Transport of Tires <br /> Q Q PRC§42953-Contracts with Registered Waste Tire Haulers. Compliance Deadline <br /> PRC§42956-Registration/Decal in Vehicle <br /> Q Q 14 CCR§18459-Responsible Entities Complying with Manifesting Requirements Date <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 n <br /> Q Q 14 CCR§18459.3-Retention of Comprehensive Trip Logs for 3 years o <br /> Q Q 14 CCR§18460.2-Manifest System Requirements for Registered Waste Tire Haulers Q Referred/CalRecycle Enforcement <br /> f <br /> Q Q 14 CCR§18461 -Manifest System Requirements for Waste Tire End-Use Facilities W <br /> Q Q 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators In Compliance-No Violations o <br /> Q 1 Q 1 Other:§ <br /> Comments ` <br /> '�'�•-1w:yt .t_ 1� r.-l:a�.[ '�,,, t ��1/.��1.�%r�� �.�(itt.'L «t/I �—���� <br /> Inspection FormIncluded: Q <br /> Comments Included: ® <br /> Business Rep's Signature Phone Number Inspector's Signature Phone Number <br /> INSTRUCTIONS ON BACK I Correct: Incorrect: �_ E X A M P L E 1112 3 62081 <br /> q] <br /> ■ White Copy:CalRecycle Yellow Copy:Operator Pink Copy:LEA <br />