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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 1 - 1226681 <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 Type(Fill one) <br /> Site Suffix: ( 6 p� 3 Q ( ® Routine Q Re inspection Q Referral Q Observation <br /> LocalIf Referral,choose referral type(Fill one) <br /> Identifier: SCLY-1 �(x��i/�� Covrl Q CHP Q CalRecycle Q Complaint Q Educational Visit Q Other <br /> Businneess or Facility Name Inspected By Inspector <br /> Physical A eS Tti <br /> C i�l� Tti �- ��^[\ ✓1/1Ze <br /> - l © <br /> 335 s S--- <br /> VV Inspection Date I 1 © l <br /> Time In t Time Out <br /> Business Rep Title ® AM (DAM <br /> 0 U 0 PM (� _ 0 PM <br /> - <br /> Operational Status Tire Type Business Role Storage Type <br /> Tire Count(Whole/PTE) <br /> (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> j c—' <br /> p J a Active Q Passenger A Generator ® Outdoor <br /> O Q Closed Q Altered <br /> GPS Latitude Q Hauler Q Indoor <br /> O Q Inactive 6 Truck <br /> Longitude - Q Planned Q OTR Q End-Use ap 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 0 Ub_''e_ TV_C_ _S� 2 <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 /> Q Q PRC§42956-Registration/Decal in Vehicle <br /> QQ 14 CCR§18459-Responsible Entities Complying with Manifesting Requirements Date M / [TI / 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 EX7) 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 /> uj <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 ®In Compliance-No Violations o <br /> Q Q Other:§ z <br /> Comments <br /> Inspection Form Included: Q �oqpof p �, ( U"Comments Included: �6 7 <br /> Business Rep's Signature Phone Number *o . <br /> Phone Number <br /> _ 62081 <br /> INSTRUCTIONS ON BACK Correct:* Incorrect: X � 1 2 3 <br /> ■ White Copy:CalRecycle Yellow Copy:Operator ® ■ <br />