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2 Waste Tire Survey & Inspection Report -Inspection Report Number <br /> Cal Rec cle State of California _ <br /> Y CalRecycle 181(Rev.10/10) I1 1226334 <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 Inspection Type(Fill one) <br /> Site Suffix: 1 n $ 0 5 r7 I 0 Routine Q Re-inspection Q Referral Q Observation <br /> Local �\ CoIf Referral,choose referral type(Fill one) <br /> Identifier: SUS J OVI lrl W ut Q CHP Q CalRecycle Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name <br /> Inspected By Inspector <br /> Physical Address CS�0 <br /> Nx- <br /> Inspection Date <br /> < A <br /> Ul Time In 11 Time Out <br /> Business Rep Title1 , 0 AM 0 AM <br /> r J e PM (6 PM <br /> cu, �ovo� ��� L'uj MQ.31WAC4 <br /> Operational Status Tire Type Business Role Storage Type <br /> Tire Count(Whole/PTE) (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> ® Active 9 Passenger ® Generator ® Outdoor <br /> Q Closed Q Altered <br /> GPS Latitude Q Hauler Q Indoor <br /> D Q Inactive fb Truck <br /> Longitude - Q Planned Q OTR Q End-Use Q Container <br /> Business Type(Fill all that apply) <br /> Q New Tire Dealer Q Auto Repair Q Trucking Fleet ® 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 /> Q Q PRC§42956-Registration/Decal in Vehicle <br /> Q Q 14 CCR§18459-Responsible Entities Complying with Manifesting Requirements Date 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) 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 /> 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 /> On <br /> Inspection Form Included: Q. - <br /> �--- 209- 331- 717 -- <br /> Comments Included: — - - -- — --- -- <br /> Business Rep's Signature Phone Number Insp or's Signatur Phone Number <br /> INSTRUCTIONS ON BACK Correct:I, Incorrect: EJXJAJ 1 1 2 3 62081 <br /> ■ White Copy:CalRecycle Yellow Copy:Operator Pink Co L © ■ <br />