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Waste Tire Survey & hspecVan ReportInspection Report Number <br /> CalRecycle State of California ) 11 - j <br /> CalRecycle 181(Rev.10/10 S v <br /> 08 <br /> Dept.of Resources Recycling and Recovery(CalRecycle) Surve '•'For _ Page <br /> Part A-Survey BLU_E OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- � Inspection Type(Fill one) <br /> Site Suffix: `j lJ f ® Routine Q Re-inspection . Q Referral Q Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier: (1 <br /> ✓1 �VQGr(�1 �C/Ll�i� Q CHP Q CalRecycle Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name Inspected By Inspector <br /> Physical Address l v � <br /> Inspection Date <br /> � cK-f�✓� C 14- <br /> Time In Time Out <br /> Business Rep Title 0 AM f 0 AM <br /> Z • 0 PM 1 0 PM <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 /> 10 Active 40 Passenger ®Generator * Outdoor <br /> o Q Closed Q Altered <br /> ��� Latitude Q Hauler Q Indoor <br /> O Q Inactive 0 Truck <br /> Longitude — Q Planned OTR Q End-Use Q Container <br /> Business Type(Fill all that apply) <br /> Q New Tire Dealer 0 Auto Repair Q 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 0 Hauler Q Agriculture Q Shredder 0 Other C y( {-��tin. LC(�Vl-�'1� <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 Q - Q Notice Of Violation Q Extension <br /> § <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 /> 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 <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 /> 2 <br /> Q Q 14 CCR§18461 -Manifest System Requirements for Waste Tire End-Use Facilities W <br /> Q 0 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators ®In Compliance-No Violations o <br /> Q Q Other:§ I /. <br /> Comments <br /> V <br /> 9 e <br /> o <br /> Inspection Form Included: Q 6;L— <br /> Comments Included: <br /> Business p's Signatur Phone Number Inspector's Signature .Phone Number <br /> INSTRUCTIONS ON BACK Correct:46 Incorrect: E X I A I M I P JLJEJ 1112 3 62081 <br /> ■ White Copy:CalRecycle Yellow Copy:Operator Pink Copy:LEA ® 0 <br />