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Waste Tire burvey & Inspection Repo L Inspection Report Number <br /> Cal Rec cle State of California <br /> Y CalRecycle 181(Rev.10/10) Survey Form - Page 1 11 12 2 6 4 0 0 <br /> Dept.of Resources Recycling and Recovery(CalRecycle) <br /> Part A-Surve _ _ BLUE OR BLACK INK PEN_ <br /> Business Profile Inspection Details <br /> e (� Inspection Type(Fill one) <br /> Site Suffix: S 5 v 0 I ® Routine Q Re-inspection Q Referral Q Observation <br /> Local \ fIf Referral,choose referral type(Fill one) <br /> Identifier: Q CHP Q CalRecycle Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name I l Inspected By Inspector <br /> Physical Address <br /> � /J gS�lS Inspection Date <br /> Time In OAM Time Out 4p AM <br /> Business Rep fii:l? IV V Q 0 /) <br /> I O PM � `J a 0 QPM <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 /> ' /1 Q Active Q Passenger Q Generator Q Outdoor <br /> O Closed Q Alter '� <br /> J� <br /> GFS Latitude ® 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 /> Q New Tire Dealer (W 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 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 EXT) N <br /> a <br /> Q O 14 CCR§18459.3-Retention of Comprehensive Trip Logs for 3 years o <br /> Q O 14 CCR§18460.2-Manifest System Requirements for Registered Waste Tire Haulers Q Referred/CalRecycle Enforcement <br /> Lu <br /> W <br /> Q O 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 Generators ®In Compliance-No Violations o <br /> Q Q Other:§ <br /> Comments <br /> "Q. <br /> 1 No Nil"�I nS (CIA5 (,vnCC-F0 <br /> �) C6" • &�1 , 55 In ti S �o y 'J +U (A Y)affie ()Lug kS)0 C 10.1 , <br /> Inspection Form Included: Q (r'/, 1 <br /> Comments Included: — 60I <br /> Yt4(�'J�7 <br /> 0 Business Rep's Signature Phone Number Inspe is Signature Phone Number <br /> INSTRUCTIONS ON BACK Correct:i, Incorrect: E X I A M L1 111213 62081 <br /> ® White Copy:CalRecycle Yellow Copy:Operator Pink Co ■ <br />