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Waste--Tire-Survey &-Inspection Report—Inspection_Report Number _■ <br />State of California I 1 -119 6 615 <br />BLUE OR BLACK INK PEN <br />CalgecyloW CalRecycle 181 (Rev. 10/10) Survey Form -Page 1 <br />Dept. of Resources Recycling and Recovery (CalRecycle) <br />Survey <br />A - Aiirvav <br />Business Profile <br />Inspection Details <br />TPID - <br />Inspection Type (Fill one) <br />Site Suffix: 15 a_ O� <br />0 Routine 0 Re -inspection 0 Referral 0 Observation <br />If Referral, choose referral type (Fill one) <br />0 CHP 0 CalRecycle 0 Complaint 0 Educational Visit 0 Other <br />Local C ` <br />Identifier v�e,��/1� �C �vV <br />LL <br />Business or Facility Name <br />Inspected By Inspector <br />fJ <br />dd 2 S <br />', 4I <br />Physical-TA.1 <br />l L O l AA ire iLA <br />Inspection Date l 7 <br />Time In Time Out <br />Business Rep Title <br />) ® AM 10 AM <br />l L _'-L J <br />O PM O PM <br />operational Status <br />Tire Type <br />Business Role <br />Storage Type <br />Tire Count (Whole/PTE)/ <br />(Fill one only) <br />(Fill all that apply) <br />(Fill all that apply) <br />(Fill all that apply) <br />�j <br />0 Active <br />0 Closed <br />0 Passenger <br />0 Altered <br />0 Generator <br />0 Hauler <br />I& Outdoor <br />0 Indoor <br />O <br />GPS Latitude <br />0 Inactive <br />® Truck <br />O <br />Longitude — <br />0 Planned <br />® OTR <br />0 End -Use <br />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 ® OtherC��yN�bV� <br />Part <br />B - <br />Inspection of Waste Tire Dealer, Generator, Hauler and End -Use Facility <br />ENFORCEMENT STATUS <br />V <br />A <br />HAULING AND MANIFEST REQUIREMENTS <br />0 Notice Of Violation 0 Extension <br />0 <br />0 <br />PRC § 42951 - Waste Tire Hauler Registration and Transport of Tires <br />0 <br />0 <br />PRC § 42953 - Contracts with Registered Waste Tire Haulers. <br />Compliance Deadline <br />0 <br />0 <br />PRC § 42956 - Registration/Decal in Vehicle <br />0 <br />0 <br />14 CCR § 18459 - Responsible Entities Complying with Manifesting Requirements <br />Date M/m/m <br />0 <br />0 <br />14 CCR § 18459.1 - Tire Program ID Number from CalRecycle <br />0 <br />0 <br />14 CCR § 18459.2.1 - Submittal of Comprehensive Trip Logs within 90 days <br />(Required for NOV or EXTJ <br />0 <br />0 <br />14 CCR § 18459.3 - Retention of Comprehensive Trip Logs for 3 years <br />0 <br />0 <br />14 CCR § 18460.2 - Manifest System Requirements for Registered Waste Tire Haulers <br />0 Referred / CalRecycle Enforcement <br />0 <br />0 <br />14 CCR § 18461 - Manifest System Requirements for Waste Tire End -Use Facilities <br />0 <br />0 <br />14 CCR § 18462 - Manifest System Requirements for Tire Dealers or Waste Tire Generators <br />® In Compliance - No Violations <br />0 <br />0 <br />Other: § <br />_- <br />Comments <br />Inspection Form Included: 0 <br />9rZ_.�9� <br />Comments Included: <br />Zo <br />Bu ' ess ep's Signat a PhoA Number In e o ' nare Phone Number <br />INSTRUCTIONS ON BACK [Correct:* Incorrect: X� NJ E XM A P E 1 2 3 62081 <br />0 White Copy: CalRecycle Yellow Copy: Operator Pink Copy: LFA ® ■ <br />