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Waste Tire Survey & Inspection Report Inspection Report Number ■ <br /> CalRecycle State of California 11 - 1226614 <br /> CalRecycle 181(Rev.10/10) Survey Form - Page 1 <br /> Dept.of Resources Recycling and Recovery(CalRecycle) BLUE OR BLACK INK PEN <br /> PartA-Surve _ - - <br /> Business Profile Inspection Details <br /> Inspection Type(Fill one) <br /> TPID- <br /> Site Suffix: ` l 1 �� G ( ® Routine Q Re-inspection Q Referral Q Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier t � w� Q CHP Q CalRecycle Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name Inspected By Inspector <br /> c.�l G'� (jlnc j l rr� �z� .,le ✓ 3 c1 _ Z <br /> Physical Address 1 <br /> � <br /> C/� Inspection Date C) ( Z <br /> cA _cb�j q Time In Time Out <br /> Business Rep Title O AM -7 O AM <br /> 'Q 0 @ PM 3 wpm <br /> L-tJG3 �f t V162 ©Lr 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 ® Active ® Passenger ®Generator Q Outdoor <br /> O Q Closed Q Altered Q Hauler I Q indoor <br /> l <br /> GPS Latitude , <br /> O <br /> Q Inactive Q Truck <br /> Longitude - Q Planned Q OTR Q End-Use Q 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 Q Hauler Q Agriculture Q Shredder ( Other <br /> Part B - Inspection of Waste Tire Dealer, Generator, Hauler and End-Use Facility ENFORCEMENT STATUS <br /> V A HAULING AND MANIFEST REQUIREMENTS 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 /> Q Q PRC§42956-Registration/Decal in Vehicle <br /> Q Q 14 CCR§18459-Responsible Entities Complying with Manifesting Requirements Date M / M / m N0 <br /> Q Q 14 CCR§18459.1 -Tire Program ID Number from CalRecycle <br /> (Required for NOV or EXE <br /> 14 CCR§18459.2.1 -Submittal of Comprehensive Trip Logs within 90 days a <br /> Q Q 14 CCR§18459.3-Retention of Comprehensive Trip Logs for 3 years o <br /> / <br /> Q Q 14 CCR§18460.2-Manifest System Requirements for Registered Waste Tire Haulers Q Referred CalRecycle Enforcement2 <br /> Lu <br /> 0, 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 O In Compliance-No Violations o <br /> Q Q Other:§ <br /> Comments <br /> Inspection Form Included: Q 1 <br /> Comments Included: 0 Phone Number <br /> Business Rep's Signature one Number spe for atu <br /> 62081 <br /> INSTRUCTIONS ON BACK Correct:* Incorrect: E X A LL 1 2 3 ■ <br /> White Copy:CalRecycle Yellow Copy:Operator Pink Co <br /> ■ <br />