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Waste Tire SL%ey & Inspection ReporAnspection Report Number ■ <br /> CalRec cle State of California m <br /> Y CalRecycle 181(Rev.10/10) Survey Form - Page I1 1177528 <br /> Dept.of Resources Recycling and Recovery(CalRecycle) <br /> Part A-Survey BLUE OR BLACK INK PEN <br /> iness Profile Inspection Details <br /> Inspection Type(Fill one) <br /> Site Suffix: I I J * Routine Q Re-inspection Q Referral O Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier: 5C(O J()6 j LA I 1 (CA � O CHP O CalRecycle O Complaint O Educational Visit O Other <br /> Business or Facility Name l Inspected By Inspector <br /> �Jlz-s, (-\ WO � (9f 1 <br /> 1f1 _ I O l <br /> Physical Addre s CS r✓(� (� <br /> q 0 c� d� S�t C"I Gt crv, � ST <br /> Inspection Date <br /> Time In Time Out <br /> Business Rep Title 0 AM 0 AM <br /> ' S 19 PM S ® PM <br /> JN ,n <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 /> O Active O Passenger ® Generator O Outdoor <br /> D O Closed O Altered NIA <br /> GPS Latitude O Hauler O Indoor <br /> O ® Inactive O Truck <br /> Longitude - O Planned ® OTR O End-Use O Container <br /> Business Type(Fill all that apply) °J <br /> New Tire Dealer O Auto Repair O Trucking Fleet O Government O Retreader O Dismantler O Tire Derived Fuel <br /> Used Tire Dealer O Auto Body O Car Dealer O Collection O Crumb Rubber <br /> O Service Station O Hauler O Agriculture O Shredder ® Other �Poej <br /> Part B - Inspection of Waste Tire Dealer, Generator, Hauler and End-Use Facility ENFORCEMENT STATUS <br /> V A HAULING AND MANIFEST REQUIREMENTS <br /> O O O Notice Of Violation O Extension <br /> PRC§42951 -Waste Tire Hauler Registration and Transport of Tires <br /> O O PRC§42953-Contracts with Registered Waste Tire Haulers. Compliance Deadline <br /> PRC§42956-Registration/Decal in Vehicle <br /> O O 14 CCR§18459-Responsible Entities Complying with Manifesting Requirements Date m / m / m <br /> O O 14 CCR§18459.1 -Tire Program ID Number from CalRecycle <br /> O O 14 CCR§18459.2.1 -Submittal of Comprehensive Trip Logs within 90 days (Required for NOV or EX7) n <br /> O O 14 CCR§18459.3-Retention of Comprehensive Trip Logs for 3 years o <br /> O O 14 CCR§18460.2-Manifest System Requirements for Registered Waste Tire Haulers O Referred/CalRecycle Enforcement <br /> uj <br /> O. <br /> w <br /> O 14 CCR§18461 -Manifest System Requirements for Waste Tire End-Use Facilities _...._.—_ <br /> O O 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators ®In Compliance-No Violations o <br /> O O Other:§ <br /> Comments <br /> 1n1 nod' <br /> ection Form Included: <br /> p O <br /> Comments Included:, <br /> 4B ,ness Rep's Signature Phone Number Insp or's Signature Phone Number <br /> INSTRUCTIONS ON BACK Correct: Incorrect: E X AM L E 1 2 3 62081 <br /> ■ White Copy:CalRecycle Yellow Copy:Operator Pink Cob <br /> ® ■ <br />