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Waste Tire Survey & Inspection Report Inspection Report Number ■ <br /> Cal Rec cle State of California <br /> Y CalRecycle 181(Rev.10/10) Survey Form - Page 1 I1 1230161 <br /> Dept.of Resources Recycling and Recovery(CalRecycle) <br /> Part A - Survey <br /> BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- Inspection Type(Fill one) <br /> Site Suffix: 6 7 ' C i Routine Q Re-inspection Q Referral Q Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier: vt� ��� Q CHP Q CalRecycle Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name C ® / Inspected By Inspector <br /> %eae. !Jam✓/Q�v2 \�rZGd— ?� i ® � 1 v <br /> Physical Address <br /> 55(S 4. VA 96vaz�-o sk. - <br /> Inspection Date <br /> Gr Y- a. C&" C�c <br /> q'523; <br /> Time In Time Out <br /> Business Rep Title u O AM z : 1 S O AM <br /> PM go PM <br /> (—��Cb— ✓�Z d.\e Z �� 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 /> 1 ® Active e Passenger • Generator 0 Outdoor ' <br /> O Q Closed Q Altered a <br /> GPS Latitude Q Hauler 0 Indoor 1 <br /> O Q Inactive Q Truck <br /> Longitude — Q Planned I& OTR Q End-Use Q Container <br /> Business Type(Fill all that apply) <br /> Q New Tire Dealer Q 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 Q Hauler Q Agriculture Q Shredder • Other �c�`b� <br /> Part B - Inspection of Waste Tire Dealer, Generator, Hauler and End-Use Facility ENFORCEMENT STATUS <br /> V I A I 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 /> Q Q 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 EXE N <br /> a <br /> 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 /> g <br /> W <br /> Q Q 14 CCR§18461 -Manifest System Requirements for Waste Tire End-Use Facilities <br /> Q Q 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators B In Compliance-No Violations o <br /> Q Q Other:§ <br /> Comments 'ZO <br /> � <br /> ���L Ce(✓\ <br /> Inspection Form Included: Q , � <br /> Comments Included: 0PA, � <br /> ) $�sacsp JLA <br /> Business Rep's Sig ture Phone Number Inspe is Signature Phone Number <br /> INSTRUCTIONS ON BACK Correct:* Inorrect: X cE X A M P L E 1112131 62081 <br /> ■ White Copy:CalRecycle Yellow Copy:Operator Pink Copy:LEA ® ■ <br />