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Waste Tire Survey & Inspection Report Inspection Report Number <br /> State of <br /> CalRecycle CalRecyclelifornia 181(Rev.10/10) — <br /> Dept.of Resources Recycling and Recovery(CalRecycle) <br /> Survey Form - Page 1 I1 1210 217 <br /> Part A-Survey BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- Inspection Type(Fill one) <br /> Site Suffix: 4-( © l ® Routine Q Re-inspection Q Referral Q.Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier: Sow, Q CHP Q CalRecycle Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name Inspected By. Inspector <br /> l- vb mcg bvC, <br /> Physical Address <br /> /C1�t� -�• • /"TUC'�`rJ Ci✓ �" — . <br /> Inspection Date <br /> CA qsar� <br /> Time In Time Out <br /> Business Rep Title 0 AM ®AM <br /> I Z L C7 0.PM I Z � D op PM <br /> XDVACJ - Operational Status Tire Type Business Role Storage Type <br /> Tire Count (Whole/PTE) (Fill one only) (FII all that apply) (Fill all that apply) (Fill all that apply) <br /> ' ' 7 to C) ® Active ® Passenger ® Generator ® Outdoor <br /> - <br /> GPS Latitude OQ Closed Q Altered <br /> 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 /> ® 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 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 <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 N <br /> a <br /> Q Q 14 CCR§18459.3-Retention of Comprehensive Trip Logs for 3 years o <br /> Q Q 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 <br /> Q O 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generatorsit In Compliance-No Violations <br /> Q Q Other:§ <br /> Comments <br /> N <br /> Inspection Form Included: Q �© �� ✓� <br /> Comments Included: ® <br /> QSS <br /> R. Signature Phone Number I sp c Si nature Phone Number <br /> INSTRUCTIONS ON BACK Correct: Incorrect: E X A E 1 1213;i 62081 <br /> ■ White Copy:CalRecycle Yellow Copy:Operator Pink Copy: EA © ■ <br />