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Oa Waste Tire Survey & Inspection Report inspection Report Number <br /> CalRecycle State of California _ I 1 - 1226691 <br /> CalRecycle 181(Rev:10/10) Survey Form Page 1 <br /> Dept.of Resources Recycling and Recovery(CalRecycle) <br /> _ BLUE OR BLACK INK PEN <br /> Part A-Survey <br /> Business Profile Inspection Details <br /> TPID- Inspection <br /> - /r> Inspection Type(Fill one) <br /> Site Suffix: 3 U v ® Routine Q Re-inspection Q Referral Q Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier: J�{l (01Af1Q CHP Q CalRecycle Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name Inspected By Inspector <br /> PhysicaiUress v <br /> Lok CA i5a�D U <br /> Inspection Date � I / 0 X / � I <br /> Time In Time Out <br /> Business Rep Title O AM Q AM <br /> / I : 3 5 ® PM ® PM <br /> J�SSQ <br /> bow _- n,� P1�51 v�n� — --- <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 /> Q Active Q Passenger Generator Q Outdoor <br /> O ® Closed Q Altered N/)Q <br /> GPS Latitude Q Hauler 0 Indoor <br /> O Q Inactive ® Truck <br /> Longitude - Q Planned Q OTR 0 End-Use 0 Container <br /> Business Type(Fill all that apply) _ <br /> Q New Tire Dealer Q Auto Repair Q Trucking Fleet Q Government Q Retreader 0 Dismantler Q Tire Derived Fuel <br /> Q Used Tire Dealer 0 Auto Body Q Car Dealer Q Collection Q Crumb Rubber <br /> Q Service Station 0 Hauler Q Agriculture Q Shredder I* Other 00_S L6 n <br /> Part B - Inspection of Waste Tire Dealer, Generator, Hauler and End-Use Facility ENFORCEMENT STATUS <br /> V A HAULING AND MANIFEST REQUIREMENTS <br /> Notice Of Violation 0 Extension <br /> O O PRC§42951 -Waste Tire Hauler Registration and Transport of Tires <br /> O O PRC§42953-Contracts with Registered Waste Tire Haulers. Compliance Deadline <br /> PRC§42956-Registration/Decal in Vehicle <br /> O O 14 CCR§18459-Responsible Entities Complying with Manifesting Requirements Date m / m / m <br /> O O 14 CCR§18459.1 -Tire Program ID Number from CalRecycle <br /> O O 14 CCR§18459.2.1 -Submittal of Comprehensive Trip Logs within 90 days (Required for NOV or Ex7) N <br /> O Q 14 CCR§18459.3-Retention of Comprehensive Trip Logs for 3 years o <br /> O O 14 CCR§18460.2-Manifest System Requirements for Registered Waste Tire Haulers O Referred/CalRecycle Enforcement <br /> Lu <br /> W <br /> O O 14 CCR§18461 -Manifest System Requirements for Waste Tire End-Use Facilities <br /> O O 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators •In Compliance-No Violations o <br /> O O Other:§ <br /> CommentsQ-0I`� i TTja! 4�1KY1-S Ulf{/t��lr1 <br /> Inspection Form Included: Q <br /> Comments Included: <br /> Business Rep's Signa ure Phone Number Inspe is Signature Phone Number <br /> INSTRUCTIONS ON BACK Correct:* Incorrect: (� E X A M 1 2 3 62081 <br /> ■ White Copy:CalRecycle Yellow Copy:Operator Pink Copy:L ■ <br />