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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 I1 - 1196661 <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^ � � o � - O ` Inspection Type(Fill one) <br /> Site Suffix: / 1 &Routine Q Re-inspection Q Referral Q Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier: (50. Oct_q V%.h �Vn `7/ Q CHP Q CalRecycle Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name 1Inspected By Inspector <br /> L l� � <br /> Physiac�rAddre�s CO <br /> CA <br /> Inspection Date 6 1 <br /> Time In Time Out <br /> Business Rep Title AM 1 & AM <br /> Q h � <br /> he 1 ' 00 0 PM 1 2 S 0 PM <br /> Operational Status Tire Type Business Role Storage Type <br /> Tire Count(Whole/PTE) z (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> .Active ® Passenger 0 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 /> New Tire Dealer • 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 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 /> 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 N <br /> Q Q 14 CCR§18459.3-Retention of Comprehensive Trip Logs for 3 years <br /> 0 <br /> Q Q 14 CCR§18460.2-Manifest System Requirements for Registered Waste Tire Haulers Q Referred/CalRecycle Enforcement <br /> 2 <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:§ <br /> Comments�v\`�y�C.�„�Ar� 1�`e-��Y�C�D 2C��Oh .n,� V�. ��•:.•��C��'�`'� �`^� <br /> BIZ VSs C�,vice c�n <br /> Inspection Form Included: Q <br /> Comments Included: <br /> Business Rep's Signature Phone Number Inspe or's Signature Phone Number <br /> INSTRUCTIONS ON BACK Correct:0 Incorrect: E X A M P L E 1112 3 62081 <br /> ■ White Copy:CalRecycle Yellow Copy:Operator Pink Copy:LEA ® 0 <br />