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Waste Tire Sul•vey & Inspection Report Inspection Report Number ■ <br /> cal Recycle State of California i 1 _ 1- 176366 <br /> CalRecycle181(Rev.10/10) Survey Form - Page 1 1 <br /> Dept.of Resources Recycling and Recovery(CalRecycle) BLUE OR BLACK INK PEN <br /> Part A- Survey _ <br /> InspectionDetails <br /> Business Profile <br /> - Q _ Inspection Type(Fill one) <br /> TPID <br /> Site Suffix: �-� C� d Routine Q Re-inspection Q Referral Q Observation <br /> Local \ If Referral,choose referral type(Fill one) <br /> Identifier: sC'y-� VOCL�,JCa;� Q CHP Q CalRecycle Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name Inspected By Inspector <br /> Physical Address c U <br /> Inspection Date _7 <br /> Time In Time Out <br /> Business Rep Title AM <br /> (6 AM <br /> O PM Z G V ® PM <br /> 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 (Whole/PTE) , ® Active ® Passenger le Generator Q Outdoor <br /> Latitude o Q Closed Q Altered Q Hauler Q Indoor <br /> GPS <br /> O Q Inactive ®Truck <br /> Longitude - Q Planned Q OTR Q End-Use ® Container <br /> Business Type(Fill all that apply) -- <br /> p New Tire Dealer Q Auto Repair ® 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 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 ®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 LA / � / <br /> 0 Q 14 CCR§18459-Responsible Entities Complying with Manifesting Requirements Date N <br /> Q Q 14 CCR§18459.1 -Tire Program ID Number from CalRecycle <br /> (Required for NOV or EX) <br /> Q Q 14 CCR§18459.2.1 -Submittal of Comprehensive Trip Logs within 90 days <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/CalReccle Enforcement y 2 <br /> W <br /> Q Q 14 CCR§18461 -Manifest System Requirements for Waste Tire End-Use Facilities -- <br /> Q O 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators Q In Compliance-No Violations o <br /> Q Q Other:§ <br /> Comments <br /> Inspection Form Included: Q _ — 144' <br /> Comments Included: ® Busin igna-its Phone Number n r gnature _-Phone Number <br /> 62081 <br /> INSTRUCTIONS ON BACK Correct:* Incorrect: � E A P L 1 2 3 <br /> White Copy:CalRecycle Yellow Copy:Operator Pink C ® ■ <br /> ■ <br />