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0 Waste Tire Su. iey & Inspection Reporti inspection Report Number <br /> calRec cle State of California — <br /> Y CalRecycle 161(Rev.10/10) Survey Form - Page 1 I1 1230188 <br /> Dept.of Resources Recycling and Recovery(CalRecycle) <br /> Part A-Survey BLUEOR OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- � p �• +1 , � � � _ � � Inspection Type(Fill one) <br /> Site Suffix: b "� 0 Routine Q Re-inspection Q Referral Q Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier: uta CC) Q CHP Q CalRecycle Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name V <br /> Inspected By Inspector <br /> Ces k-c o 1 I 3 q - k 0 <br /> Physical Address <br /> - <br /> ��` 6 CA 9 Sz4o Inspection Date <br /> Time in 1 Time Out 1 <br /> Business Rep Title�p � Z U � 0 AM 0 AM <br /> a 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 /> ® Active 9 Passenger 0 Generator Q Outdoor <br /> Q Closed Q Altered <br /> GPS Latitude Q Hauler 0 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 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 /> V A 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 /> PRC§42956-Registration/Decal in Vehicle <br /> Q 0 14 CCR§18459-Responsible Entities Complying with Manifesting Requirements Date m / / m <br /> Q Q 14 CCR§18459.1 -Tire Program ID Number from CalRecycle A <br /> Q Q 14 CCR§18459.2.1 -Submittal of Comprehensive Trip Logs within g0 days (Required for NOV or EXT) N <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 W <br /> Q 0 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators 4P In Compliance-No Violations o <br /> Q 1 Q 1 Other:§ <br /> Commentst-� - ���Vt *��t�� ��5�-C_�iO�p,, C�32��'�- G�V� ��•�ZC�?�� �,�� �' <br /> -- <br /> Inspection Form Included: 0lwvl�f�raA X(O r 3IJ9�4a�F 4wt <br /> c�g- Ib <br /> Comments Included: <br /> Business Rep's Signature Phone Number Inspec or's Signature Phone Number <br /> INSTRUCTIONS ON BACK Correct:0 Incorrect: IEIXIAIMIPILIEI 11 2 3 62081 <br /> ■ White Copy:CalRecycle Yellow Copy:Operator Pink Copy:LEA ® 0 <br />