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Waste Tire Survey & Inspection Report- Inspection Report Number <br /> State of California <br /> CalRecycle — <br /> CalRecycle181(Rev.10/10) Survey Form - Page 1 I1 1230288 <br /> Dept.of Resources Recycling and Recovery(CalRecycle) <br /> PartA-_Survey _ BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- L � ^ � Inspection Type(Fill one) <br /> �Site Suffix: 1 ® Routine Q Re-inspection Q Referral Q Observation <br /> Local1 If Referral,choose referral type(Fill one) <br /> Identifier: sac., Q CHP Q CalRecycle Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name Inspected By Inspector <br /> 1 <br /> Physical Ad&4 } n CA - l Q ES O'S-Tfj <br /> 1 � Inspection Date <br /> 1 Time In Time Out <br /> Business Rep Title 1 d AM 1 AM <br /> t S O Q PM { 0 PM <br /> Srr��s s Parks ch �. <br /> i 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 /> 4b Active ® Passenger 0 Generator Q Outdoor <br /> O Q Closed Q Altered <br /> GPS Latitude Q Hauler ® Indoor <br /> O Q Inactive Q Truck <br /> Longitude - Q Planned Q OTR Q 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 ® 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 <br /> 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 EXE 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 /> 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 Op In Compliance-No Violations o <br /> Q Q Other:§ !^1 <br /> Comments �r(�+i�I5 e, (An"' + <br /> Inspection Form Included: Q <br /> Comments Included: ® `� <br /> Bu '"sp, ature Phone Number Inspe t is Signature hone Number <br /> 62081 <br /> INSTRUCTIONS ON BAC Correct:* Incorrect: X 17,y� EXAM E 1 1273 <br /> ■ White Copy:CalRecycle Yellow Copy:Operator Pink Copy:L A <br />