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Waste Tire .S6. Vey & Ms pection Repon Inspection Report Number <br /> State of California <br /> alRecyc a CalRecycle 181(Rev.10/10) 1242159Survey Form - Page I1 <br /> Dept.of Resources Recycling and Recovery(CalRecycle) <br /> Part A-Survey BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- Inspection Type(Fill one) <br /> Site Suffix: / c/,, a ( # Routine Q Re-inspection Q Referral Q Observation <br /> Local \ If Referral,choose referral type(Fill one) <br /> Identifier: i1 —X�i� �� G1� Q CHP Q CalRecycle Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name 111 Inspected By Inspector <br /> Physical Address 14L/ � 5 li r �r v 1 i!I L�7L.)L/T <br /> Inspection Date <br /> G� ����1� Time In / Time Out l T <br /> Business Rep Title 0 AM 0 AM <br /> j ' .2- 0 ® PM !:37 ® PM <br /> Operational Status Tire Type Business Role Storage Type <br /> (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> Tire Count(Whole/PTE) (Fill one only) <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 /> 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 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 N <br /> Q Q 14 CCR§18459.2.1 -Submittal of Comprehensive Trip Logs within 90 days (Required for NOV or EXT) N <br /> r <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 /> 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 /> Inspection Form Included: Q <br /> Comments Included: lD <br /> Business Rep's Signature Phone Number Ins a tor' gnature Phone Number <br /> INSTRUCTIONS ON BACK Correct:* Incorrect: XA Awe 9 JJIEXAM 1 2 3 62081 <br /> ■ White Copy:CalRecycle Yellow Copy:Operator Pink op <br />