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Waste Tire S.arvey & Inspection Repor,, Inspection Report Number ■ <br /> Cal Rec cle State of California <br /> Y CalRecycle 181(Rev.10/10) Survey Form - Page 1 I1 - 1226341 <br /> Dept.of Resources Recycling and Recovery(CalRecycle) <br /> Part A-Survey BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- '5 � � � � D l Inspection Type(Fill one) <br /> Site Suffix: • Routine Q Re-inspection Q Referral Q Observation <br /> Local -T If Referral,choose referral type(Fill one) <br /> Identifier: 5(�{� J (,(meq 141 f\ Cu�l1k _ Q CHP Q CalRecycle Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name II Inspected By Inspector <br /> cr <br /> Physical Address W Zp�6) <br /> Inspection Date 3 / I W ,, j <br /> n �SZZ 0 w <br /> (�M` U Time In Time Out <br /> Business Rep TitleO AM I O AM <br /> ® PM ® PM <br /> 0 15 <br /> Operational Status Tire Type Business Role Storage Type <br /> Tire Count(Whole/PTE) 15 (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> Z <br /> ® Active Q Passenger ® Generator 9 Outdoor <br /> O Q Closed Q Altered <br /> GPS Latitude Q Hauler ® Indoor <br /> O Q Inactive ® 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 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 /> 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 /> a <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 /> uj <br /> w <br /> Q Q 14 CCR§18461 -Manifest System Requirements for Waste Tire End-Use Facilities __.. <br /> Q Q 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators <br /> In Compliance-No Violations o <br /> Q Q Other:§ <br /> Commen#s � �� v` s I () <br /> \1 ms'L <br /> Inspection Form IncludedjBu;siness <br /> P� <br /> Comments Included - — - — a `� <br /> ep' ignat a Phone Number Inspe t is Signature Phone Number <br /> — --- 62081 <br /> INSTRUCTIONS ON BACK Correct: Incorrect: EXAM L E 1 2 3 <br /> ■ White Copy:CalRecycle Yellow Copy:Operator Pink Co : © ■ <br />