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Waste Tire Survey & Inspection Report Inspection Report Number ■ <br /> CalRecycle State <br /> alRecyclel1fornia 181(Rev.10/10) 11 - 1230414 <br /> Dept.of Resources Recycling and Recovery(calRecycle) Survey Form - Page 1 <br /> Part A- Survey _ BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- Inspection Type(Fill one) <br /> Site Suffix: ' y G( $ l ® Routine 0 Re-inspection 0 Referral 0 Observation <br /> Local ` If Referral,choose referral type(Fill one) <br /> Identifier: JG�V� �b0.�.�� CbWV 0 CHP 0 CalRecycle 0 Complaint 0 Educational Visit 0 Other <br /> Business or Facility Name Inspected By Inspector <br /> Physical Address 3 t <br /> 14 9.b Sao, os Av-c,- <br /> Inspection Date <br /> CA Time In Time Out <br /> Business Rep y� Title ,L '/ O AM O AM <br /> L► C,\ 1 C_L_ /G���� !�(9tJVl lel t°� ' Q U ® PM � apPM <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 0 Passenger 0 Generator 0 Outdoor <br /> 0 Closed 0 Altered <br /> GPS Latitude 0 Hauler ® Indoor <br /> O 0 Inactive 0 Truck <br /> Longitude — 0 Planned 0 OTR 0 End-Use 0 Container <br /> Business Type(Fill all that apply) <br /> 0 New Tire Dealer 0 Auto Repair 0 Trucking Fleet 0 Government 0 Retreader 0 Dismantler 0 Tire Derived Fuel <br /> 0 Used Tire Dealer 0 Auto Body 0 Car Dealer 0 Collection 0 Crumb Rubber <br /> 0 Service Station 0 Hauler 0 Agriculture 0 Shredder ® 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 /> 0 0 PR - 0 Notice Of Violation 0 Extension <br /> C§42951 Waste Tire Hauler Registration and Transport of Tires <br /> 0 0 PRC§42953-Contracts with Registered Waste Tire Haulers. Compliance Deadline <br /> PRC§42956-Registration/Decal in Vehicle <br /> 0 0 14 CCR§18459-Responsible Entities Complying with Manifesting Requirements Date <br /> M / m / m <br /> 0 0 14 CCR§18459.1 -Tire Program ID Number from CalRecycle <br /> 0 0 14 CCR§18459.2.1 -Submittal of Comprehensive Trip Logs within 90 days (Required for NOV or EXE N <br /> 0 0 14 CCR§18459.3-Retention of Comprehensive Trip Logs for 3 years <br /> 0 <br /> 0 0 14 CCR§18460.2-Manifest System Requirements for Registered Waste Tire Haulers 0 Referred/CalRecycle Enforcement <br /> f <br /> 0 0 14 CCR§18461 -Manifest System Requirements for Waste Tire End-Use Facilities w <br /> 0 0 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators ®In Compliance-No Violations o <br /> 0 0 Other:§ <br /> Comments <br /> OF <br /> Inspection Form IncludVONCK <br /> Comments Includ - <br /> R Ignature Phone Number 44gn ture Phone Number <br /> 62081 <br /> INSTRUCTIO �Correct:e Incorrect: E X A 11 12T3] <br /> 0 White Co :pyCalRecycle Yellow Copy:Operator Pink Copy:L A © ■ <br />