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Waste Tire Survey & Inspection Report Inspection Report Number <br /> CalRecycle CalStte of Recyclel' ia 181n(Rev.10/10) <br /> Survey Form - Page 1 I1 - 1177837 <br /> Dept.of Resources Recycling and Recovery(CalRecycle) <br /> Part A- Survey BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- 1 � � � � � � _ © I Inspection Type(Fill one) <br /> Site Suffix: t ® Routine Q Re-inspection Q Referral Q Observation <br /> Localt If Referral,choose referral type(Fill one) <br /> Identifier: SGl{� J&eq(Ai^ C( n� Q CHP Q CalRecycle Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name Inspected By Inspector <br /> �n T W e s4 <br /> Physical Address <br /> Inspection Date <br /> CA 1sx5 11 <br /> Time In Time Out <br /> Business Rep Title ^ 0 AM ,l 0 AM <br /> Dav! v 0 PM V ® PM <br /> Operational Status Tire Type Business Role Storage Type <br /> y <br /> Tire Count(Whole/PTE) (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> I <br /> 0 Active Q Passenger 0 Generator Q Outdoor <br /> O Q Closed Q Altered <br /> GPS Latitude Q Hauler 0 Indoor <br /> O Q Inactive ® Truck <br /> Longitude — Q Planned ® OTR Q End-Use Q Container <br /> Business Type(Fill all that apply) 66114 <br /> Q New Tire Dealer Q Auto Repair 0 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 ® Other -Jecl R1kn,t,7ct.J-WJcr <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 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 EXE <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 In Compliance-No Violations o <br /> Q Q &1&1 <br /> (Other: <br /> Comments C�.191A �GvS lir n OJV111urgP�f��! ,5 ( ( - �1 n 'f �d 1��t,Ji�h <br /> N c� yi ol(t howls ni cuicAAc7�' C,OtI�_err1. <br /> Inspection Form Included: <br /> Comments Included: — <br /> iness Rep's Signature Phone Number Insp_ or's Signature Phone Number <br /> INSTRUCTIONS ON BACK Correct:* Incorrect: E X A M P E Z1 1213'1 62081 <br /> ■ White Copy:CalRecycle Yellow Copy:Operator Pink Copy: FJ1 © 0 <br />