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03 Waste Tire Stey & Inspection Report Inspection Report Number <br /> Cal Rec cle State of California — <br /> Y CalRecycle 181(Rev.10/10) Survey Form - Page 1 I1 1256000 <br /> Dept.of Resources Recycling and Recovery(CalRecycle) <br /> Part A- Survey BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- Inspection <br /> Inspection Type(Fill one) <br /> / <br /> Site Suffix: -2 6 6 (Do J 0 Routine Q Re-inspection Q Referral Q Observation <br /> Local ^ If Referral,choose referral type(Fill one) <br /> Identifier: � G V; co VVNQ CHP Q CalRecycle Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name V <br /> Inspected By Inspector <br /> 1121 <br /> Physical Addressc �^ {� h/� <br /> 713132- 7r fr � V6f-a" Ski <br /> /� <br /> �� ��706 Time <br /> Date <br /> \L Time In TimeOut <br /> VVv <br /> Bushiness Rep Title 2- : 1 O AM O O AM <br /> )�TT'�S 5►'l 'CC.1'�t��C. O PM S � 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 /> 2 v 0 Active Q Passenger 40 Generator 0 Outdoor <br /> O Q Closed Q Altered <br /> GPS Latitude Q Hauler Q Indoor <br /> O Q Inactive 9 Truck <br /> Longitude - Q Planned Q OTR Q End-Use Q Container <br /> Business Type(Fill all that apply) <br /> Q New Tire Dealer Q Auto Repair 7 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 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 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 EX7) N <br /> 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 /> 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 /> tA <br /> Inspection Form Included: Q `G � <br /> Comments Included: <br /> E(ul��/� <br /> siness Rep's Signature Phone Number Inspector's Signature Phone Number <br /> INSTRUCTIONS ON BACK Correct:6 Incorrect: X 4EXAMPLE 11213 62081 <br /> ■ White Copy:CalRecycle Yellow Copy:Operator Pink Copy:LEA © ■ <br />