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Waste Tire Su, vey & Inspection Report Inspection Report Number <br /> Cal Rec cle State of California <br /> Y CalRecycle 181(Rev.10/10) 11 - 1210329 <br /> Dept.of Resources Recycling and Recovery(CalRecycle) Survey Form - Page 1 <br /> BLUE OR BLACK INK PEN <br /> Part A-Survey <br /> Business Profile Inspection Details <br /> TPID- ` , " Inspection Type(Fill one) <br /> Z <br /> Site Suffix: 1 ", 'l 4P Routine Q Re-inspection Q Referral Q Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier: ��aq v Q CHP Q CalRecycle Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name V <br /> Inspected By Inspector <br /> Physical Address <br /> L <br /> Inspection Date f � � 3 / � 3 <br /> K [(� Time In 17 Time Out <br /> Business Rep Title O AM 2 O AM <br /> PM PM <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 /> j' Q Active QPas <br /> ® ginger Q Generator %Q Outdoor <br /> O Closed Q Altered <br /> GPS Latitude <br /> O Q Inactive Q Truck Q Hauler Q Indoor <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 Q Other <br /> Part B- Inspection of Waste Tire Dealer, Generator, Hauler and End-Use Facility ENFORCEMENT STATUS <br /> VA-]HAULING AND MANIFEST REQUIREMENTS <br /> Q Notice Of Violation Q Extension <br /> Q Q <br /> 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 /> 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 EXT) <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 40 In Compliance-No Violations o <br /> Q Q Other:§ <br /> Comments�`��� �`n�•�."riCl�__ QLD-_'T���__..-(L���d�fJ�—\� �, <br /> p\V LuJ- VvO <br /> 1v o off. � o c J�NC'2S..S d COV-�-C-ear lle\ <br /> Inspection Form Included: Q -C,t ,1� �AC,�r��G�rz�t <br /> Comments Included: 0 PusAineSsRepW's <br /> v) _l LY ! o J <br /> Signature Phone Number Inspect 's Signature Phone Number <br /> �,{ 62081 <br /> INSTRUCTIONS ON BACK Correct: Incorrect: X g E X A M P L E 1 2 3 <br /> White Copy:CalRecycle Yellow Copy:Operator Pink Copy:LEA <br />