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2 Waste Tire Su. ✓ey & Inspection Report Inspection Report Number <br /> cal Recycle State of California I 1 - 1210368 <br /> CalRecycle 181(Rev.10/10) Survey Form - Pay 1 <br /> Dept.of Resources Recycling and Recovery(CalRecycle) <br /> Part A-Survey - _ _ BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- � C) � Inspection Type(Fill one) <br /> Site Suffix: "� ® Routine Q Re-inspection Q Referral Q Observation <br /> Local �A If Referral,choose referral type(Fill one) <br /> V ty" W <br /> Identifier: �dp� lijv% Q CHP Q CalRecycle Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name Inspected By Inspector <br /> so okv Sckv, add �t 4vo `D; 0 M/� '`T <br /> Physical Address <br /> �1 oll E , �k 120 <br /> Inspection Date <br /> 9533L <br /> Time In Time Out <br /> Business Rep TitleAM t 7 O AM <br /> S PM ` / s 0 PM <br /> Operational Status Tire Type Business Role Storage Type <br /> Tire Count (Whole/PTE) (t (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> Active Passenger Is Generator 0 Outdoor <br /> O Q Closed Q Altered <br /> GPS Latitude ®Hauler Q Indoor <br /> O Q Inactive `Truck <br /> Longitude — Q Planned 0 OTR Q End-Use Q Container <br /> Business Type(Fill all that apply) <br /> Q New Tire Dealer Q Auto Repair Q Trucking Fleet • 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 /> Q Q 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 EXT) <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 /> 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 Oin Compliance-No Violations o <br /> Q Q Other:§ I <br /> Comments Q�o J t� _ 2. Lim CLS�e_ �A'f'Q- r So e_c l`\O V\ A-oyte on ��,S CSI <br /> \ " W c�s 1n o <br /> r AlrCoyxcec)n <br /> Inspection Form Included: Q 014�Wl,�72 a <br /> ", 1�kl 4��A &7 <br /> Comments Included: <br /> B siness Rep's Signature Phone Number Insp tor's Signature Phone Number <br /> __]j <br /> INSTRUCTIONS ON BACK Correct:* Incorrect: X*q <br /> E X A M P ! L E 1 2 3 62081 <br /> White Copy:CalRecycle Yellow Copy:Operator Pink Copy:LEA <br />