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Waste Tire *Vey & Ins ection Re oloInspection Report Number <br /> CalRec cle State of California -1176353 ■ <br /> Y CalRecycle 181(Rev.10/10) Survey Form - Page 1 I1 117 6 3 5 3 <br /> Dept.of Resources Recycling and Recovery(CalRecycle) <br /> Part A- Survey <br /> _ BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- ` Inspection Type(Fill one) <br /> Site Suffix: / O 1 O Routine Q Re-inspect 1! i9 t� 0,, <br /> efepP Y Observation <br /> �Local �� � � � If Referral,choose r ( <br /> Identifier: (�W✓t� Q CHP Q CalRecycle Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name Inspected By Inspector <br /> Cal i 6Y✓t,l '� +(f_e_1A � - <br /> Physical Address l 0 l At�v 4y2:t mbv1C' <br /> v1 Ener 4v� <br /> n � ��j Inspection Date � / © � / <br /> `dc� Time In Time Out <br /> BusinessRepTitle O AM �j 5 O AM <br /> 1Y�r� 3�� C�ylL1C ✓ 0 PM LX ® PM <br /> Operational Status Tire Type Business Role Storage Type <br /> Tire Count(Whole/PTE) <br /> (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> ' ID Active ® Passenger ® Generator ® Outdoor <br /> Q Closed Q Altered <br /> GPS Latitude Q Hauler Q 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 ® 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 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 <br /> 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 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 EXE <br /> Q O 14 CCR§18459.3-Retention of Comprehensive Trip Logs for 3 years <br /> Q O 14 CCR§18460.2-Manifest System Requirements for Registered Waste Tire Haulers Q Referred/CalRecycle Enforcement <br /> Q Q 14 CCR§18461 -Manifest System Requirements for Waste Tire End-Use Facilities w <br /> i <br /> Q Q 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators <br /> in Compliance-No Violations o <br /> Q Q Other:§ <br /> Comments <br /> Inspection Form Included: Q 4att�e/ <br /> Comments Included: ® 6_73B eIn t ss Re s Signature Phon Nu Phone Number <br /> INSTRUCTIONS ON BACK Correct:0 Incorrect: E WA M 1 2 3 62081 <br /> ■ White Copy:CalRecycle Yellow Copy:Operator Pink Copy:L <br />