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Waste Tire Survey & Inspection Report Inspection Report NumberState of <br /> ■ <br /> CalRecycle calRecyclelifornia 181(Rev.10/10) I 1 - 1210 5 5 2 <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: •� �1 C.i 1 0 Routine Q Re-inspection Q Referral Q Observation <br /> Local l II If Referral,choose referral type(Fill one) <br /> Identifier: �G'���1 L Y�LLL� ✓�� �; wL h1 Q CHP Q CalRecycle Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name Inspected By Inspector <br /> 1 <br /> Physical Address� i ���� ���l���S �� l j �1� �y i ✓� <br /> 1 R <br /> Inspection Date <br /> Time In I Time Out <br /> Business Rep �! ( Title O AM O AM <br /> 1-4 0 ® PM �2_ ® PM <br /> VYU Operational Status Tire Type Business Role Storage Type <br /> (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> Tire Count (Whol T <br /> ' 1 ­20 ® Active *Passenger ®Generator 4p Outdoor <br /> Q Closed Q Altered <br /> GPS Latitude Q Hauler Q 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 /> 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 /> Q Q PRC§42956-Registration/Decal in Vehicle <br /> Q Q 14 CCR§18459-Responsible Entities Complying with Manifesting Requirements Date M / m / m <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 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 /> LU <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 1 Q Other:§ <br /> Comments <br /> Imo? <br /> Inspection Form Included: 0 <br /> Comments Included: ® <br /> Business Rep's Signature Phone Number . Insp or' gna l;e Phone Number <br /> INSTRUCTIONS ON BACK Correct:I, Incorrect: W �� E X A M 1 2 3 62081 <br /> White Copy:CalRecycle Yellow Copy:Operator Pink Copy: ® 0 <br />