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Waste Tire SL- .ey & Inspection Repo spection Report Number <br /> Cal Rec cle State of California J <br /> Y CalRecycle 181(Rev.10/10) Survey Form - Page 1 11 - _ 176605 <br /> Dept.of Resources Recycling and Recovery(CalRecycle) <br /> Part A-Survey BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- u Inspection Type(Fill one) <br /> Site Suffix: / $ 9 Routine Q Re-inspection Q Referral Q Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier: � � C Q CHP Q CalRecycle Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name_ Inspected By Inspector <br /> �A"V"' <br /> Physical Address <br /> Inspection Date o} ci- <br /> Time In Time Out <br /> Business Rep Title ® AM 10 AM <br /> ` a 0P 1 © ® 0P <br /> /A 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 /> 0 ' Q Active Q Passenger Q Generator Q Outdoor <br /> o ® Closed Q Altered <br /> GPS Latitude Q Hauler Q Indoor <br /> O Q Inactive Q 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 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 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 0P <br /> Q Notice Of Violation Q Extension <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 <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 EXT) 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 /> Lu <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 S In Compliance No Violations o <br /> Q Q Other:§ <br /> Comments <br /> 1(owjnom, 4,-Ar n <br /> Inspection Form Included: 0 1 <br /> Comments Included: ® �'� <br /> a�.�-ufc�r Cz )Y6�—C'li 3 <br /> Business Rep's Signature Phone Number `Inspector's Signature Phone Number <br /> INSTRUCTIONS ON BACK Correct:40 Incorrect: E X A P L 1 2 3 62081 <br /> ■ White Copy:CalRecycle Yellow Copy:Operator Pink Co` :L © ■ <br />