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Waste Tire Su►vey & Inspection Report Inspection Report Number <br /> calRec cle state of California — <br /> Y CalRecycle 181(Rev.10/10) Survey Form Page 1 11 1230264 <br /> Dept.of Resources Recycling and Recovery(CalRecycle) <br /> Part A-Survey BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- Q ` t �� _ h 1 Inspection Type(Fill one) <br /> Site Suffix: 1 _` V 0 Routine Q Re-inspection Q Referral Q Observation <br /> Local /� \ If Referral,choose referral type(Fill one) <br /> Identifier: \ 6 0_1�� (O� e Q CHP Q CalRecycle Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name J Inspected By Inspector <br /> \\') <�­T-,a C��' Ya ,i T" <br /> Physical Address A- <br /> CA- <br /> U <br /> Inspection Date 2 / 2 / 1 <br /> Time In Time Out <br /> Business Rep Title O AM1 77..�� O AM <br /> � Z ' O PM ( 'Z V ® PM <br /> 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 /> 40 Active • Passengerg 0 Generator • Outdoor)17 <br /> o Q Closed Q Altered <br /> GPS Latitude Q Hauler 0 indoor 35 <br /> O Q Inactive !Truck <br /> Longitude — Q Planned Q OTR Q End-Use ® Containerg <br /> Business Type(Fill all that apply) <br /> Q New Tire Dealer Q Auto Repair 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 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 <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 /> QQ 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 EXT) N <br /> a <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 /> uj <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 Q Other:§ <br /> Comments <br /> y�S ( ohC PVI <br /> Inspection Form Included: Q4L <br /> coq- Y <br /> Comments Included: <br /> Business Rep's Signature Phone Number Inspec is dignature Phone Number <br /> INSTRUCTIONS ON BACK I Correct:* Incorrect: 707q?] EXAMPLE 1 2 3 62081 <br /> ■ White Copy:CalRecycle Yellow Copy:Operator Pink Copy:LEA ® 0 <br />