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Waste Tire Survey & Inspection Repot ` Inspection Report Number <br /> cal Recycle State of California I.1_ - 1226501 <br /> CalRecycle 181(Rev.10/10) Survey Form - Page 1 <br /> Dept.of Resources Recycling and Recovery(CalRecycle) BLUE O R BLACK INK PEN <br /> Part A-Survey — _. <br /> Business Profile Inspection Details <br /> TPID- Inspection Type(Fill one) <br /> Site Suffix: -7 Q 0 Routine Q Re-inspection Q Referral Q Observation <br /> LocalIf Referral,choose referral type(Fill one) <br /> Identifier: �Ot tG `,1� � '��L / Q CHP Q CalRecycle Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name - ---t <br /> Inspected By Inspector <br /> Physical Address l d lyd VYI�-j <br /> Inspection Date / C) C/ l <br /> Time In Time Out <br /> l ` <br /> Business Rep Title O AM O AM <br /> \ pZ U Q PM ® ® PM <br /> Operational Status Tire Type Business Role Storage Type <br /> (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> Tire Count (Whole/PTE) 1 -^� <br /> / p 11) Active ® Passenger Q Generator 4* Outdoor <br /> PS Latitude O Q Closed Q Altered 41, Hauler Q Indoor <br /> G <br /> O Q Inactive ®Truck <br /> Longitude - Q Planned Q OTR Q End-Use ® 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 ® 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 ®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 m <br /> Q 14 CCR§18459-Responsible Entities Complying with Manifesting Requirements Date M Mc� o , N <br /> Q Q 14 CCR§18459.1 -Tire Program ID Number from CalRecycle <br /> Q Q 14 CCR§184 - (Required for NOV or EXT) N <br /> 59.2.1 Submittal of Comprehensive Trip Logs within 90 days <br /> Q Q 14 CCR§18459.3-Retention of Comprehensive Trip Logs for 3 years o <br /> 0 Q 14 CCR§18460.2-Manifest System Requirements for Registered Waste Tire Haulers ®Referred/CalRecycle Enforcement <br /> W <br /> Q Q 14 CCR§18461 -Manifest System Requirements for Waste Tire End-Use Facilities <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 /> Inspection Form Included: Q <br /> Comments Included: ® Bus Hess Rep's Signature Phone Number s cto s gnature Phone Number <br /> 62081 <br /> INSTRUCTIONS ON BACK Correct:I* Incorrect: E X AMP L E 1 2 3 <br /> ■ White Copy:CalRecycle Yellow Copy:Operator Pink Copy:LEA ® ■ <br />