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Waste Tire Su. Bey & Inspection Report Inspection Report Numbe. <br /> Cal Rec cle State of California <br /> Y CalRecycle 181(Rev.10/10) Survey Form --Page 1 11 1230202 <br /> Dept.of Resources Recycling and Recovery(CalRecycle) <br /> Part A- Survey_ BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- Inspection Type(Fill one) <br /> Site Suffix: C) Q / 3 0 I 1* Routine Q Re-inspection Q Referral Q Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier: so-y\ Too-q' <br /> ,s�� �V� Q CHP Q CalRecycle Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name Inspected By Inspector <br /> PhysaC AdreV J [ - 0 k <br /> Li E)o <br /> C� q S 33 Inspection Date I 1 / 1, 9 <br /> Mate�-`,p�0. / I / <br /> ` � Time In Time Out I <br /> Business Rep Title AM 1 + � � O PM <br /> I o C)Q, c` ' S Q PM 1 <br /> Operational Status Tire Type Business Role Storage Type <br /> Tire Count (Whole/PTE) (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> 0 Active Q Passenger &Generator • Outdoor <br /> Q Closed Q Altered <br /> GPS Latitude Q Hauler Q Indoor <br /> O Q Inactive 40 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 6 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 F11 <br /> m <br /> Q Q 14 CCR§18459-Responsible Entities Complying with Manifesting Requirements Date 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 /> Q Q 14 CCR§18459.3-Retention of Comprehensive Trip Logs for 3 years N <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 •In Compliance-No Violations o <br /> Q Q Other:§ ` <br /> Comments ('Ove y 0.S ,C h G S C <br /> ��i� 2oq-y6g 3zs <br /> Inspection Form Included: Q <br /> Comments Included: • <br /> siness Rep' 1gnature Phone Number Inspec or's Signature Phone Number <br /> INSTRUCTIONS ON BACK rrect:41 correct: E X A M P L 62081 E 1 2 3 <br /> White Copy:CalRecycle Yellow Copy:Operator Pink Copy:LEA <br />