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Waste Tire Survey & Inspection Repor,, Inspection Report NumberState of <br /> ■ <br /> Cal Recycle CalRecycle1181(Rev.10/10) 11 - 1226651 <br /> Dept.of Resources Recycling and Recovery(CalRecycle) Survey Form - Page 1 <br /> Part A- Survey BLUE OR R BLACK INK PEN <br /> Business Profile Inspection Details <br /> Inspection Type(Fill one) <br /> St Suffix: I 5 l l 1 l (& Routine Q Re-inspection Q Referral Q Observation <br /> LocalP 1 If Referral,choose referral type(Fill one) <br /> c_. <br /> Identifier: '(��/� �� �/� ot.^" Q CHP Q CalRecycle Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name 11 Inspected By Inspector <br /> Physical Address (, l <br /> �l (' 'J Inspection Date / Q / 1 <br /> �5�� Time In Time Out l <br /> Business Rep Title 0 AM l 0 AM <br /> PM / CJ 0 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 /> ® Active Q Passenger ® Generator 0 Outdoor <br /> O Q Closed Q Altered <br /> GPS Latitude Q Hauler Q Indoor <br /> O Q Inactive 0 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 ® 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 EXE <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 /> 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 <br /> In Compliance-No Violations o <br /> Q Q Other:§ <br /> Comments ` <br /> Inspection Form Included: Q <br /> Comments Included: ® —y6 <br /> _=54�Busi s p's Signature Phone Number n e r' iqAa!jlre Phone Number <br /> INSTRUCTIONS ON B CK Correct:0 incorrect: [E-1 X A M L 12 3 62081 <br /> White Copy:CalRecycle Yellow Copy:Operator Pink Cop : © 0 <br />