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Waste Tire Survey & Inspection Report Inspection Report Number <br /> CalRecycle state of California I 1 1 7 6373 <br /> CalRecycle 181(Rev.10/10) Survey Form - Page 1 1 .111...J <br /> Dept of Resources Recycling and Recovery(CalRecycle) BLUE OR BLACK INK PEN <br /> Part A-Survey <br /> Business Profile Inspection Details <br /> TPID- Inspection Type(Fill one) <br /> Site Suffix: ' FJ 0 _ 9 O I ® Routine Q Re-inspection Q Referral Q Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier. Sao )n",", � C��� Q CHP Q CalRecycle Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name Inspected By Inspector <br /> D P Ctt <br /> Physical Address ( � C6 Zai <br /> Ap! Inspection Date <br /> ` <br /> n`� '���^ Time In Time Out <br /> Business R p Title ® AM O AM <br /> QPM v ® PM <br /> �.r Operational Status Tire Type Business Role Storage Type <br /> (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> Tire Count (Whole/PTE) , 1 ® Active ® Passenger ® Generator ® Outdoor <br /> O Q 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 ® Auto Repair Q Trucking Fleet Q Government Q Retreader Q Dismantler Q Tire Derived Fuel <br /> 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 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 N <br /> Q Q 14 CCR§18459.1 -Tire Program ID Number from CalRecycle <br /> Q Q 14 CCR§18 (Required for NOV or EXT) N <br /> 459.2.1 -Submittal of Comprehensive Trip Logs within 90 days <br /> Q Q 14 CCR§18459.3-Retention of Comprehensive Trip Logs for 3 years o <br /> Q Q Q Referred/CalRecycle Enforcement <br /> 14 CCR§18460.2-Manifest System Requirements for Registered Waste Tire Haulers $ <br /> Lu <br /> Q O 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 /> - U <br /> Comments S C <br /> Ocl <br /> Ot <br /> ibc Sc r Onajn <br /> Inspection Form Included: Q <br /> Comments Included: III& <br /> Business Rep' g "lure Phone Number Inspe t is Sign ure ne Number <br /> 62081 <br /> INSTRUCTIONS ON BACK Correct e Incorrect: � � g EX A M E 1 2 3 <br /> ■ White Copy:CalRecycle Yellow Copy:Operator Pink EA ® 0 <br />