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Waste Tire Survey & Inspection Repon Inspection Report Number <br /> State CalRecycle CalRecfcleli181 Rev.10/10 ■ <br /> CalRecycle Survey Form - Page 1 I1 1196392 <br /> Dept.of Resources Recycling and Recovery(CalRecycle)_ BLUE OR BLACK INK PEN <br /> Part A-Survey <br /> Business Profile Inspection Details <br /> TPID- 1 Inspection Type(Fill one) <br /> Site Suffix: 3 S 0 1 • Routine Q Re-inspection Q Referral Q Observation <br /> Locall,t, f Referral,choose referral type(Fill one) <br /> Identifier: <br /> Sa(1TUU�,q i� CoOLI� Q CHP Q CalRecycle Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name l <br /> Inspected By Inspector <br /> Physical Address <br /> 1 l lJ CJLC� <br /> u� Inspection Date Ck(✓� � Time In Time Out <br /> Business Repl Tiittle ® AM ® AM <br /> 0 o PM 1 v QPM <br /> Operational Status Tire Type Business Role Storage Type <br /> Tire Count (Whole/PTE) 1 1 (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> 1 ® Active ® Passenger ® Generator ® Outdoor <br /> O Q Closed Q Altered <br /> GP� Latitude Q Hauler Q Indoor <br /> O Q Inactive Q Truck <br /> Longitude — Q Planned Q OTR 0 End-Use Q Container <br /> Business Type(Fill all that apply) <br /> Q 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 9 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 <br /> Q Q 14 CCR§18459.1 -Tire Program ID Number from CalRecycle N <br /> Q Q 14 CCR§18459.2.1 -Submittal of Comprehensive Trip Logs within 90 days (Required for NOV or EX) <br /> Q Q 14 CCR§18459.3-Retention of Comprehensive Trip Logs for 3 years <br /> Q O 14 CCR§18460.2-Manifest System Requirements for Registered Waste Tire Haulers Q Referred/CalRecycle Enforcement g <br /> Q O 14 CCR§18461 -Manifest System Requirements for Waste Tire End-Use Facilities _ W <br /> Q O 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators <br /> in Compliance No Violations o <br /> Q Q Other:§ <br /> < <br /> Comments o-, A4JnL_(UN 4�NS,CIA c, <br /> _w\n om 0 C) K)-CA <br /> No Ni a6�_ t,_„s os CA le'us.—4 e.1a r c oa n- <br /> Inspection Form Inclu d: 0 7-,::e <br /> � Y <br /> Comments Inclu a !'Q( t`�(� <br /> Business ature Phone Number Insp41jDr1s Signature Phone Number <br /> INSTRUCTIONS ON BACK Correct:* Incorrect: �} � � EXAM L E 1 2 3 62081 <br /> White Copy:CalRecycle Yellow Copy:Operator Pink Cop L ® 0 <br />