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Waste Tire Suivey & Inspection Repork. Inspection Report NumberState of <br />■ <br />CalRecycle CalRecyclel'fornia 181 (Rev. 10/10)I1 - 1226594 <br />Dept. of Resources Recycling and Recovery (CalRecycle) Survey Form - Page 1 <br />. BLUE OR BLACK INK PEN <br />rat L�-vJM VYY_- <br />Business Profile <br />Inspection Details <br />TPID - h <br />Site Suffix: I 6 Q 0 V <br />Inspection Type (Fill one) <br />0 Routine Q Re -inspection Q Referral Q Observation <br />If Referral, choose referral type (Fill one) <br />Q CHP Q CalRecycle Q Complaint Q Educational Visit Q Other <br />Local , <br />Identifier:-Sckv\, t�/1� <br />Business or Facility Name <br />Inspected By Inspector <br />e:).( �o� s <br />Physical Addr s <br />- 1 0 ( ,�-►-�, <br />✓ }-��n A n _ <br />Business Rep Title <br />Inspection Date Q / Z '� 1 <br />Time In Time Out <br />O AM O AM <br />2 ' 2 0 ® PM �� ® PM <br />Operational Status <br />(Fill one only) <br />®Active <br />Q Closed <br />Q Inactive <br />Q Planned <br />Tire Type <br />(Fill all that apply) <br />®Passenger <br />Q Altered <br />Q Truck <br />Q OTR <br />Business Role <br />(Fill all that apply) <br />a Generator <br />Q Hauler <br />Q End -Use <br />Storage Type <br />(Fill all that apply) <br />®Outdoor <br />Q Indoor <br />Q Container <br />Tire Count (Whole/PTE) <br />� <br />GPS Latitude <br />0 <br />Longitude - <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 />® 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 <br />B - <br />Inspection of Waste Tire Dealer, Generator, Hauler and End -Use Facility <br />ENFORCEMENT STATUS <br />Q Notice Of Violation Q Extension <br />V <br />A <br />HAULING AND MANIFEST REQUIREMENTS <br />— <br />Q <br />Q <br />PRC § 42951 - Waste Tire Hauler Registration and Transport of Tires <br />Q <br />Q <br />PRC § 42953 - Contracts with Registered Waste Tire Haulers. <br />Compliance Deadline <br />Q <br />Q <br />PRC § 42956 - Registration/Decal in Vehicle <br />Q <br />Q <br />14 CCR § 18459 - Responsible Entities Complying with Manifesting Requirements <br />Date <br />Q <br />Q <br />Q <br />Q <br />14 CCR § 18459.1 - Tire Program ID Number from CalRecycle <br />14 CCR § 18459.2.1 - Submittal of Comprehensive Trip Logs within 90 days <br />(Required for NOV or EXE <br />Q <br />Q <br />14 CCR § 18459.3 - Retention of Comprehensive Trip Logs for 3 years <br />Q <br />Q <br />14 CCR § 18460.2 - Manifest System Requirements for Registered Waste Tire Haulers <br />Q Referred / CalRecycle Enforcement <br />Q <br />Q <br />14 CCR § 18461 - Manifest System Requirements for Waste Tire End -Use Facilities <br />_ <br />Q <br />Q <br />14 CCR § 18462 - Manifest System Requirements for Tire Dealers or Waste Tire Generators <br />® In Compliance - No Violations <br />Q <br />Q <br />Other: § <br />Comments <br />5&f_6. . en Lt -' <br />Inspection Form Included: Q -57u <br />Comments Included: t <br />siness Rep's Signature Phone Number fns s g ture Phone Number <br />INSTRUCTIONS ON BACK <br />[Correct- S1 Incorrect: X <br />E <br />X <br />A <br />M <br />P <br />L <br />I E 1 <br />1 <br />2 <br />3Q <br />62081 <br />■ White Copy: CalRecycle Yellow Copy: Operator Pink Copy: LEA <br />■ <br />