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Waste Tire St ey & Inspection Repor Inspection Report Number <br /> Cal Rec cle State of California — <br /> Y CalRecycle 181(Rev.10/10) Survey Form - Page 1 I1 1242116 <br /> lR <br /> Dept.of Resources Recycling and Recovery(Caecycle) <br /> Part A-Survey _ BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- t t ' O � _ O ` Inspection Type(Fill one) <br /> Site Suffix: "1 1 * Routine Q Re-inspection Q Referral Q Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier: S �� �b�V;T\ co V Q CHP Q CalRecycle Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name Inspected By Inspector <br /> Physical Address <br /> Inspection Date Q O � 2 2 / <br /> ��c \-o�n C CK2Id <br /> Time In Time Out <br /> Business Rep Title 0 AM 0 AM <br /> / ` ( — ` 2 ' 2 S 0 PM 2 ' � S 0 PM <br /> 1.k��h C�a•� L�C�.0Ac� Operational Status Tire Type Business Role Storage Type <br /> ` <br /> Tire Count(Whole/PTE) (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> 1 <br /> a Active 0 Passenger * Generator Q Outdoor <br /> O Q Closed Q Altered <br /> GPS Latitude Q Hauler Q Indoor <br /> O Q Inactive 9 Truck <br /> Longitude — Q Planned Q OTR Q End-Use C ainer <br /> Business Type(Fill all that apply) <br /> Q New Tire Dealer Q Auto Repair 0 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 <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 /> 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 EXT) <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 In Compliance-No Violations o <br /> Q Q Other:§ \ \ <br /> Comments <br /> k5^e.-. J�1f�C <br /> RAS C2S <br /> Inspection Form Included: Q <br /> Comments Included: <br /> - of t 2cfl�y b$'-3Z� <br /> Busine i re Phone Number Insp tor's Signature Phone Number <br /> _�"] <br /> INSTRUCTIONSON BACK Correct:* Incorrect: X EXAMPLE 2 3 62081 <br /> 1 <br /> White Copy:CalRecycle Yellow Copy:Operator Pink Copy:LEA <br />