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Waste Tire St.. vey & Inspection Repork Inspection Report Number <br /> Cal Recucle State of California <br /> J CalRecycle 181(Rev.10/10) 1 1226518 <br /> Dept.of Resources Recycling and Recovery(CalRecycle) Survey Form - Page 1 <br /> BLUE OR BLACK INK PEN <br /> Part A -Survey- <br /> Business Profile Inspection Details <br /> TPID- /^� l Inspection Type(Fill one) <br /> Site Suffix: l I © lJ t ® Routine Q Re-inspection Q Referral Q Observation <br /> Local \,, If Referral,choose referral type(Fill one) <br /> Identifier: '(XV� �)(Dck��/1 r` CC I r✓L Q CHP Q CalRecycle Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name Inspected By Inspector <br /> eG-"r-r" C G _ i <br /> Physical Address (� l A-Y�M b L) <br /> CAO A <br /> Inspection Date �1 / —7t / <br /> C,� �" ''� ` Time In C� Time Out C <br /> Business Rep Title ] O AM y O AM <br /> Q ® PM ` Zf O 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 ® Passenger ® Generator Q Outdoor <br /> � Q Closed Q Altered <br /> GPS Latitude Q Hauler ® Indoor <br /> 0 Q Inactive Q Truck <br /> Longitude - Q Planned Q OTR Q End-Use Q Container <br /> Business Type(Fill all that apply) <br /> 0 New Tire Dealer Q 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 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 EXT) N <br /> v <br /> N <br /> Q Q 14 CCR§18459.3-Retention of Comprehensive Trip Logs for 3 years o <br /> Q Q 14 CCR§18460.2-Manifest System Requirements for Registered Waste Tire Haulers Q Referred/CalRecycle Enforcement <br /> f <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 <br /> 1 <br /> i <br /> i <br /> Inspection Form Included: Q <br /> Comments Included: ®Eu - oPink <br /> s Rep's Signature Phone Numberis S' n ure Phone Number <br /> 62081 <br /> INSTRUCTIONS ON BAC Correct: Incorrect: M L E 1 Z 3 <br /> ■ White Copy:CalRecycle Yellow Copy:Operator :L ® ■ <br />