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2 Waste Tire S... - *-.%Oy & Inspection Repo^spection Report Number <br /> Cal Recycle State of California 11 - 1176 5 3 4 <br /> CalRecycle 181(Rev.10/10) Survey Form - Page 1 <br /> Dept.of Resources Recycling and Recovery(CalRecycle) BLUE OR BLACK INK PEN <br /> Part A-Survey _ __ -- - - _ <br /> Business Profile Inspection Details <br /> TPID- Inspection Type(Fill one) <br /> Site Suffix: I y / V / r ® Routine Q Re-inspection Q Referral Q Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier: ^-p yu Q CHP Q CalRecycle Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name Inspected By Inspector <br /> E LL—CC) <br /> Physical Address <br /> 30 <br /> C Inspection Date o <br /> Time In Time Out <br /> AM <br /> Title © O AM 0 .2 : a ® PM <br /> Bus'in/ess Rep � � 3 ® 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 /> iActive 0 Passenger ® Generator ® Outdoor <br /> O Q Closed Q Altered <br /> GPS Latitude Q Hauler Q Indoor <br /> O Q Inactive ® Truck <br /> Longitude - Q End-Use Q Container <br /> Q Planned Q QTR <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 <br /> STATUS <br /> rPRC 42951 -Waste Tire Hauler Registration and Transport of Tires Q Notice Of Violation Q Extension <br /> V A HAULING AND MANIFEST REQUIREMENTS <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 o <br /> Q Q 14 CCR§18459.2.1 -Submittal of Comprehensive Trip Logs within 90 days (Required for NOV or EX7) <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 <br /> ®In Compliance-No Violations o <br /> Q Q Other:§ L <br /> Comments <br /> fLfifYY[� ltd C_ I C', <br /> OE If <br /> Inspection Form Included: Q x <br /> Comments Included: ® — LZOF -Ob j <br /> Business Rep's Signature Phone Number Inspector's Signature hone Number <br /> INSTRUCTIONS ON BACK Correct: Incorrect: ��] E I X I A I M L E 1 2 3 62081 <br /> White Copy:CalRecycle ' Yellow Copy:Operator Pink Co :L <br />