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Waste Tire Survey & Inspection Report Inspection Report Number ■ <br /> Cal Rec cle State of California <br /> Y CalRecycle 181(Rev.10/10) Survey Form - Page 1 I1 - 1226367 <br /> Dept.of Resources Recycling and Recovery(CalRecycle) <br /> Part A- Surve',, BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- � � � � � C � _ O � Inspection Type(Fill one) <br /> Site Suffix: l 40 Routine Q Re-inspection Q Referral Q Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier: ���(,(, *�1 P, C(�l,(�>1 O CHP Q CalRecycle 0 Complaint Q Educational Visit O Other <br /> Business or Facility Name (� Inspected By Inspector <br /> Physical Address 3 1 V ES <br /> 3ss-0 <br /> Inspection Date � / 0 <br /> J moi' Time In Time Out <br /> Business Rep Title1 1- ' O AM () O AM <br /> A�n \e-n (��trncjc„r�w� j. 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 O Passenger ® Generator Q Outdoor <br /> O Q Closed O Altered <br /> GPS Latitude Q Hauler ® Indoor <br /> 0 Q Inactive Q Truck <br /> Longitude - Q Planned ® OTR O End-Use O 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 ® 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 /> 0 Q PRC§42953-Contracts with Registered Waste Tire Haulers. Compliance Deadline <br /> PRC§42956-Registration/Decal in Vehicle <br /> O O 14 CCR§18459-Responsible Entities Complying with Manifesting Requirements Date <br /> M / m / m <br /> O O 14 CCR§18459.1 -Tire Program ID Number from CalRecycle <br /> O O 14 CCR§18459.2.1 -Submittal of Comprehensive Trip Logs within 90 days (Required for NOV or EXT) <br /> O O 14 CCR§18459.3-Retention of Comprehensive Trip Logs for 3 years <br /> O O 14 CCR§18460.2-Manifest System Requirements for Registered Waste Tire Haulers Q Referred/CalRecycle Enforcement <br /> O O 14 CCR§18461 -Manifest System Requirements for Waste Tire End-Use Facilities u, <br /> Q O 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators In Compliance-No Violations o <br /> 0 O Other:§ L L <br /> Comments roj VsA7 2J {� <br /> (� v -J U 11ti�i'a�� C� Ck1c.c,s <br /> Inspection Form Included: O ? �(,/_�► �l (x' <br /> Comments Included: ®- — �- '� �J - -- <br /> Business Rep's Signature Phone Number Inspe o 's Signature _ Phone Number <br /> 62081 <br /> INSTRUCTIONS ON BACK Correct: Incorrect: FETx-FAWN L It 12 13] <br /> 0 White Copy:CalRecycle Yellow Copy:Operator Pink Co y: A ® ■ <br />