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Oa Waste Tire Su. Bey & Inspection Report Inspection Report Number <br /> CalRecle State of California <br /> cycle CalRecycle 181(Rev.10/10) 1210344Survey Form - Page 1 I1 <br /> Dept.of Resources Recycling and Recovery(CalRecycle) <br /> Part A-Survey BLUEO_R BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- Inspection� � � � Inspection Type(Fill one) <br /> Site Suffix: O 0 Routine Q Re-inspection Q Referral Q Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier: q CoV v­')�-y Q CHP Q CalRecycle Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name --` Inspected By Inspector <br /> h Y\ , \ <br /> Physical Address ` <br /> CAvl s 30% l Inspection Date <br /> Time In Time Out <br /> Business Rep 11 l Title '-` 0 AM C 0 AM <br /> ��L 9OS W�l` YvtwtpYl. CD�`�OV\ 1 � � � �PM � J O O 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 /> (� ! Active . Passenger 0 Generator Q Outdoor <br /> O Q Closed Q Altered <br /> GPS Latitude 0 Hauler Q Indoor <br /> O Q Inactive 0 Truck <br /> Longitude - Q Planned. • OTR Q End-Use 0 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 <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 E)C7) N <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/CalRecycle Enforcement <br /> LU <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 /> - - ��'. �1�o ,J►��o be �c S o C0V\Czc r <br /> Inspection Form Included: 4 7 114;&AL 2ol-Li ba--s2zj� <br /> Comments Included: <br /> Business Rep's Signature Phone Number Inspec or's Signature Phone Number <br /> INSTRUCTIONS ON BACK Correct:0 Incorrect: K*Rq] E X A M P L E 1 2 3 62081 <br /> ® White Copy:CalRecycle Yellow Copy:Operator Pink Copy:LEA ® 1 0 <br />