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Waste Tire SL. ✓ey & Inspection Repori Inspection Report Number ■ <br /> Cal Recycle State of California I 1 - 1226339 <br /> CalRecycle 181(Rev.10/10) <br /> (Cal Survey Form - Page 1 <br /> Dept.of Resources Recycling and Recovery(CalRecycle) <br /> Part A - Survey BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- >� y� I r, I - Q I Inspection Type(Fill one) <br /> Site Suffix: (J "( ® Routine Q Re-inspection Q Referral Q Observation <br /> Local � � ;n Co��� If Referral,choose referral type(Fill one) <br /> Q� ��� <br /> Identifier: Q CHP Q CalRecycle Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name <br /> Inspected By Inspector <br /> Net'ntln& 6� (aI,tUlnlo- <br /> Physical Address <br /> Inspection Date 3 / � � � 1 a <br /> Time In Time Out <br /> Business Rep Title O AM r� O AM <br /> ' 0 P �7 1 5 ® PM <br /> — <br /> Operational Status Tire Type Business Role Storage Type <br /> Tire Count(Whole/PTE) (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> Active Q Passenger ® Generator ® Outdoor <br /> Q Closed Q Altered <br /> GPS Latitude Q Hauler Q Indoor <br /> D Q Inactive • Truck <br /> Longitude - Q Planned ® OTR Q End-Use Q Container <br /> Business Type(Fill all that apply) C <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 0 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 <br /> Q Q 14 CCR§18459.3-Retention of Comprehensive Trip Logs for 3 years <br /> Q Q 14 CCR§18460.2-Manifest System Requirements for Registered Waste Tire Haulers Q Referred/CalRecycle Enforcement <br /> 2 <br /> Q Q 14 CCR§18461 -Manifest System Requirements for Waste Tire End-Use Facilities w <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 11 c <br /> � L 11 <br /> c�,STc.� � � <br /> 3 Om <br /> d i()_�_Ao ,S_ bl 4)Lkus (T� e-oneern. <br /> Inspection Form Included: Q p <br /> Comments Included: AW <br /> Business Rep's Signature Phone Number Inspe r s Signature Phone Number <br /> 62081 <br /> INSTRUCTIONS ON BACK Correct_ Incorrect_ JjEjXjAjPf 1 2 3 <br /> ■ White Copy:CalRecycle Yellow Copy:Operator Pink Cop LE <br />