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Waste Tire Survey & Inspection Report Inspection Report Number <br /> Cal Rec cle State of California <br /> Y CalRecycle 181(Rev.10/10) Survey Form - Page 1 I1 - 1226369 <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: i L f�i 5 t-� 9 Routine Q Re-inspection Q Referral 0 Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier. ✓� �rX-� �.1� LAlY1, Q CHP Q CalRecycle Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name v Inspected By Inspector <br /> Physic Add s S / (-) ' 4,?,m Jul-j <br /> Inspection Date / a 7 / z <br /> CA c-"3U�l Time In Time Out C— <br /> Business Rep 1 Title 0 AM 0 AM <br /> Q PM O -3 a PM <br /> Operational Status Tire Type Business Role Storage Type <br /> Tire Count(Whole <br /> (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> TE <br /> G"� � ® Active ® Passenger ® Generator ® Outdoor <br /> Q Closed Q Altered <br /> GPS Latitude 0 Hauler 0 Indoor <br /> O Q Inactive Q Truck <br /> Longitude - Q Planned Q OTR 0 End-Use Q Container <br /> Business Type(Fill all that apply) <br /> Q New Tire Dealer 0 Auto Repair Q Trucking Fleet Q Government Q Retreader Q Dismantler Q Tire Derived Fuel <br /> Q Used Tire Dealer Q Auto Body ® 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 /> O O <br /> PRC§42951 -Waste Tire Hauler Registration and Transport of Tires <br /> Q 0 PRC§42953-Contracts with Registered Waste Tire Haulers. Compliance Deadline <br /> O Q PRC§42956-Registration/Decal in Vehicle <br /> O Q 14 CCR§18459-Responsible Entities Complying with Manifesting Requirements Date M / M / m <br /> O 0 14 CCR§18459.1 -Tire Program ID Number from CalRecycle w <br /> O Q 14 CCR§18459.2.1 -Submittal of Comprehensive Trip Logs within 90 days (Required for NOV or EX7J <br /> O Q 14 CCR§18459.3-Retention of Comprehensive Trip Logs for 3 years <br /> O O 14 CCR§18460.2-Manifest System Requirements for Registered Waste Tire Haulers Q Referred/CalRecycle Enforcement <br /> Lu <br /> W <br /> O O 14 CCR§18461 -Manifest System Requirements for Waste Tire End-Use Facilities <br /> O O 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators In Compliance-No Violations o <br /> O Other:§ <br /> Comments <br /> f <br /> Inspection Form Included: Q �' l <br /> Z )"VY2�/ '6) -�r6 2d <br /> Comments Included: <br /> Business Rep's Signature Phone Number I s ctor' S' nature Phone Number <br /> -- 62081 i <br /> INSTRUCTIONS ON BACK Correct: Incorrect: E X A L 1 2 3 <br /> ■ White Copy:CalRecycle Yellow Copy:Operator Pink Co y: ® ■ <br />