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Waste Tire S#ey & Inspection Reporii, Inspection Report Number <br /> CalRecycle CalRecyc e1181(Rev.10/10) 11 — 5 3 0 3 <br /> Dept.of Resources Recycling and Recovery(CalRecycle) <br /> Survey Fora - Page 1 I . 2 <br /> Part A-Survey BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- r Inspection Type(Fill one) <br /> Site Suffix: I Q Routine Q Re-inspection 0 Referral Q Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier: '�`� f�of V1 C' Q CHP 0 CalRecycle Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name _L Inspected By Inspector <br /> V-e V,rcy-) 7 i-cw 5/xIoutco-n (10. <br /> Physical Address �✓(WwV`a'ItGS�f <br /> stC j Inspection Date ( / 1 <br /> 1 Time In Time Out <br /> Business Rep Title 7 Q AM 7� 0 AM <br /> 1 �V aPM Z ' U 40PM <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 /> -- ' _ ' Q Active QPas. sQnger Q Generator Q 0 t or <br /> o 0 Closed Q Altered <br /> GPS Latitude Q Hauler Q 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 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 Q Q Notice Of Violation Q Extension <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 /> PRC§42956-Registration/Decal in Vehicle <br /> Q Q 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 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 /> 2 <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 ®In Compliance-No Violations o <br /> Q 1 Q 1 Other:§ I I <br /> Comments i o' QMH CNS �l.t�� G a-k"I �['►�CJ� <br /> (vl t.c)C4 r�G I C1 V M 1GPG uy � C & Pte. 014 CoYz C�yj'L.,D-. <br /> taml B cr <br /> Inspection Form Included: O ?83 aZ T <br /> Comments Included: Q <br /> Business Rep's Signature Phone Number tfnspectorrsSignature Phone Number <br /> INSTRUCTIONS ON BACK Correct:* Incorrect: X � EXAMPLE 1 2 3 62081 <br /> ■ White Copy:CalRecycle Yellow Copy:Operator Pink Copy:LEA ® ■ <br />