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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 11 1177712 <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 Type(Fill one) <br /> Site Suffix: ::` j �j ,� (� , ® Routine Q Re-inspection Q Referral Q Observation <br /> LocalIf Referral,choose referral type(Fill one) <br /> Identifier. SG,h cc.'rv"� covvv� Q CHP Q CalRecycle Q Complaint Q Educational Visit Q Other <br /> Business <br /> 'or Facility Name Inspected By Inspector <br /> C o_\ff1-'L% A-L �v l�V Y1'C:�n11 G <br /> Physical Address - j d t F&ffrk2 ui-4 <br /> C Inspection Date 7 550 <br /> Time In Time Out <br /> Business Rep TitleII 0 AM ll 0 AM <br /> l <br /> Z- ( 5 G PM t � l � ® 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 /> r ®Active ® Passenger ® Generator 0 Outdoor <br /> O Q Closed Q Altered <br /> GPS Latitude Q Hauler Q Indoor <br /> 0 Q Inactive Q Truck <br /> Longitude - Q End-Use ®Container <br /> Q Planned Q OTR <br /> Business Type(Fill all that apply) <br /> Q New Tire Dealer Q Auto Repair Q Trucking Fleet Q Government Q Retreader a 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 /> PRC§42956-Registration/Decal in Vehicle <br /> Q Q 14 CCR§18459-Responsible Entities Complying with Manifesting Requirements Date 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 <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 /> Q Q 14 CCR§18461 -Manifest System Requirements for Waste Tire End-Use Facilities w <br /> Q Q 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators Q In Compliance-No Violations o <br /> Q Q Other:§ <br /> Comments ` <br /> r <br /> oe <br /> i .. <br /> i <br /> Inspection Form Included; Q <br /> Comments Included: ® 4 - <br /> ` �-� <br /> usi�ssep's Signature Phone Number sp c s gn re Phone Number <br /> INSTRUCTIONS ON BACK Correct:0 Incorrect: E X P L 1 2 13 62081] <br /> ■ White Copy:CalRecycle Yellow Copy:Operator Pink py: © ■ <br />