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Waste Tire Sup vey & Inspection Report Inspection Report Number ■ <br /> CalRec cle State of California - 1242272 Y CalRecycle 181(Rev.10/10) 11 12 4 2 2 7 2 <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- U �7 Inspection Type(Fill one) <br /> Site Suffix: ' 3 5 5 I L O 0 Routine Q Re-inspection Q Referral Q Observation <br /> Local ` If Referral,choose referral type(Fill one) <br /> Identifier: S CJx\ � V\r co Q CHP Q CalRecycle Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name 7 Inspected By Inspector <br /> VeA Mme . ���- -2 q - X 0 1 M �' v <br /> Physical Address <br /> rInspection Date 02- / l <br /> CO ` y <br /> � Time In Time Out <br /> Business Rep Title ( ` `� 0 AM O AM <br /> 1 1 ,7 0 O pM � 2 � � *PM <br /> Operational Status Tire Type Business Role Storage Type <br /> Tire Count (Whole/PTE) <br /> (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> ' <br /> * Active Q Passenger & Generator Q Outdoor <br /> O Q Closed Q Altered <br /> GPS Latitude Q Hauler 0 Indoor <br /> O Q Inactive Q Truck <br /> Longitude — Q Planned 0 OTR Q End Use Q Container <br /> Business Type(Fill all that apply) t-14 <br /> Q New Tire Dealer Q Auto Repair Q Trucking Fleet Q Government Q Retreader 0 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 0 Other D IS'C4 Tt0'(\ (P_V� - <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 PRC§42953-Contracts with Registered Waste Tire Haulers. Compliance Deadline <br /> Q Q PRC§42956-Registration/Decal in Vehicle <br /> Q O 14 CCR§18459-Responsible Entities Complying with Manifesting Requirements Date <br /> Q Q 14 CCR§18459.1 -Tire Program ID Number from CalRecycle <br /> Q O 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 Q 14 CCR§18460.2-Manifest System Requirements for Registered Waste Tire Haulers Q Referred/CalRecycle Enforcement <br /> f <br /> Lu <br /> Q Q 14 CCR§18461 -Manifest System Requirements for Waste Tire End-Use Facilities <br /> Q O 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 /> �2 <br /> 10 1 <br /> Inspection Form Included: Q "/�7a —j7n t2-�L� <br /> � 731V_ , - <br /> Comments Included: <br /> Business Rep's Si ature Phone Number Inspec is Signature Phone Number <br /> �( 62081 <br /> INSTRUCTIONS ON BACK FCorre7ct-67Incorrect: X � NE X A M P L E 1 2 3 <br /> 0 White Copy:CalRecycle Yellow Copy:Operator Pink Copy:LEA © ■ <br />