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- -Waste-Tire-Slur-ve-y-&Inspection-Repor-t----Inspection_Report-Number_. <br /> te of <br /> CalRecycle CaaRecycleltfornia 181(Rev.10/10) I1 - 1196614 <br /> Dept.of Resources Recycling and Recovery(CalRecycle) Survey Form - Page 1 <br /> Part A-Survey BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- Inspection Type(Fill one) <br /> Site Suffix: ` 3 3 5 Q l 0 Routine Q Re-inspection Q Referral Q Observation <br /> LocalCC \ If Referral,choose referral type(Fill one) <br /> Identifier: _.�o'n JOcA"� (�(ova L, Q CHP Q CalRecycle Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name t Inspected By Inspector <br /> Physic dress lot int��1 e) (�4 <br /> moll <br /> At , <br /> n Inspection Date <br /> G/1 Time In l of Time Out <br /> Business Rep Title 10 AM ®AM <br /> l l ' O b O PM t l 3 3 O PM <br /> Operational Status Tire Type Business Role Storage Type <br /> Tire Count(Whole <br /> (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> PT <br /> • Active • Passenger ® Generator ® Outdoor <br /> O Q Closed Q Altered <br /> GPS Latitude Q Hauler Q Indoor <br /> O Q Inactive Q Truck <br /> Longitude — Q Planned Q OTR ® 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 /> (S 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 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 <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 EXE <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 /> 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 <br /> In Compliance-No Violations o <br /> Q Q Other:§ <br /> Comments <br /> ee, Com <br /> Inspection Form Included: Q ,A Q <br /> Comments Included: <br /> Business hep's Signature Phone Number Ins e o s i <br /> ' gn re Phone Number <br /> INSTRUCTIONS ON BACK Correct:* Incorrect: EXAM E 11213 62081 <br /> ■ White Copy:CalRecycle Yellow Copy:Operator Pink Cop .L © ■ <br />