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Waste Tire Su. ,iey & Inspection Report Inspection Report Number <br /> State of California <br /> CalRecycle <br /> CalRecycle 161(Rev.10/10) Survey Form - Page 1 I 1 1196680 <br /> Recycle) <br /> Dept of Resources Recycling and Recovery(CalRecycle) Survey <br /> Part A-Survey BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- I / � y, � � i - � I Inspection Type(Fill one) <br /> Site Suffix: b -L b .Routine Q Re-inspection Q Referral Q Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier: ��h V; �VN�, Q CHP Q CalRecycle Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name _V 4 _`7 Inspected By Inspector <br /> ?�_>Ace s ,�Q 5 3 9 - t o l l ` <br /> Physical Address �� V <br /> way -- ` <br /> Inspection Date , I 2 2 l <br /> ` p gS2ot <br /> Time In Time Out <br /> Business Rep Title �j O AM O AM <br /> 1z * PM 1 � � ® PM <br /> Operational Status Tire Type Business Role Storage Type <br /> Tire Count(Whol PTE 1 r (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> ' t 7 0 Active 0 Passenger ® Generator 0 Outdoor <br /> Q Closed Q Altered <br /> GPS Latitude Q Hauler Q Indoor <br /> 0 Q Inactive Q Truck <br /> Longitude - Q Planned 0 OTR Q End-Use Q Container <br /> Business Type(Fill all that apply) <br /> Q New Tire Dealer * 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 0 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 Q 14 CCR§18459-Responsible Entities Complying with Manifesting Requirements Date m Ffl <br /> / 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 90 days (Required for NOV or EXT) 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 /> 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 <br /> 'ane- \\c�►w`.v`� ��.zs wo <br /> e� CSS C,r5�Y� <br /> Inspection Form Included: Q <br /> Comments Included: ZCJ� 2 i z0+woo--3z <br /> sin ss Rep's ignature Phone Number Inspector's Signature Phone Number <br /> INSTRUCTIONS ON BACK Correct:a Incorrect: X_*__1 EXAMPLE 1 2 3 62081 <br /> ■ White Copy:CalRecycle Yellow Copy:Operator Pink Copy:LEA ® ■ <br />