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Re of l�"spection Report Number <br /> � Waste Tire ey & Inspectionp O <br /> CalRecycle Caate of Recycle1tfornia 181(Rev.10/10) e 1 I1 - 1176402 <br /> Dept.of Resources Recycling and Recovery(CalRecycle) Survey Form - Page <br /> BLUE OR BLACK INK PEN <br /> Part A- Survey <br /> Business Profile Inspection Details — <br /> TPID- Inspection Type(Fill one) <br /> Site Suffix: ` O v b ® Routine Q Re-inspection Q Referral Q Observation <br /> LocalN If Referral,choose referral type(Fill one) <br /> Identifier: Is JvU�� _I r\ C(�Un], Q CHP Q CalRecycle Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name Inspected By Inspector <br /> �r OAddre <br /> Physical �-C�Ut U�C Lr� <br /> (,() <br /> V7 Inspection Date <br /> -�S(.un 1 Time In Time Out <br /> Business Rep Title <br /> n 0 AM � AM <br /> y� NAA4xwc, `4'SO ILL O 0 PM O 0 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) <br /> Active ® Passenger 46 Generator 0 Outdoor <br /> 0 Q Closed Q Altered <br /> GPS Latitude Q Hauler Q Indoor <br /> O Q Inactive * Truck <br /> Longitude - Q Planned • OTR IN 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 I* Collection Q Crumb Rubber <br /> f <I v <br /> Q Service Station Q Hauler Q Agriculture Q Shredder 1* 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 N <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 EX7) 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 /> 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 •to Compliance-No Violations o <br /> 0 , 0 Other:§ <br /> Comments acok �11� <br /> Inspection Form Included: Q <br /> Comments Included: �n, or's Signature one Number <br /> — Busine p's gnature Phone Number <br /> 62081 <br /> INSTRUCTIONS ON BACK Correct:* Incorrect: ( D E X A P E 1 2 3 <br /> . White Copy:CalRecycle Yellow Copy:Operator Pin Copy: © • <br />