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Waste Tire Sufy & Inspection Report .iiapection Report Number <br /> CalRec cle state of California <br /> Y CalRecycle 181(Rev.10/10) Survey Form - Page 1 I1 1245363 <br /> Dept.of Resources Recycling and Recovery(CalRecycle) <br /> Part A- Survey BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- 7575 1O Inspection Type(Fill one) <br /> Site Suffix: 1 0 Routine Q Re-inspection Q Referral Q Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier: ��� �B v`n �Uf M Q CHP Q CalRecycle Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name Inspected By Inspector <br /> Ph sical Address ^ <br /> 2, 9 - � O � M�'T I- V <br /> k Cl �-7o W . C�ca�� L;re 6'. <br /> Inspection Date / O 2 / I S <br /> 1 Cu Time In Time Out <br /> Business Rep Title 1 1 I AM ® AM <br /> O PM S � O PM <br /> Operational Status Tire Type Business Role Storage Type <br /> Tire Count(Whole/PTE) 2 (Fill one only) (Fill ail that apply) (Fill all that apply) (Fill all that apply) <br /> J 0 Active Q Passenger *Generator 0 Outdoor <br /> O Q Closed Q Altered <br /> GPS Latitude Q Hauler 0 Indoor <br /> O Q Inactive 0 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 0 Other F-Cz c� <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 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 <br /> 0 <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 Other:§ <br /> Comments �0 11M JAIL i <br /> t Vej <br /> Inspection Form Included:�Q -e A_4v,�p <br /> Comments Included: <br /> Business Rep's Signature Phone Number Insp tor's Signature Phone Number <br /> INSTRUCTIONS ON BACK Correct: Incorrect: EXAMPLEj 1112L3] 62081 <br /> White Copy:CalRecycle Yellow Copy:Operator Pink Copy:LEA <br />