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Inspection Report Number <br /> Waste Tire Survey & Inspection Report � <br /> CalRec cle State of California <br /> Y CalRecycle 181(Rev.10/10) Survey Form - Page 1 I1 - 1242323 <br /> Dept.of Resources Recycling and Recovery(CalRecycle) <br /> Part A-Survey BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- t� �'] � _ qt Inspection Type(Fill one) <br /> Site Suffix: �Q lJ / [ (� ® Routine Q Re-inspection Q Referral Q Observation <br /> Local /�� If Referral,choose referral type(Fill one) <br /> Identifier: S C kO J oI CLl-t n (DLL9 1 � Q CHP Q CalRecycle Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name Inspected By Inspector <br /> Physical Address C�SC�T� <br /> Inspection Date <br /> �rrC• CV Camp G A q,sa3 <br /> Time In Time Out <br /> Business Rep Title IO 0 AM 1 l ; S _5 0 AM <br /> 0 PM 0 PM <br /> k 10AC5 <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 /> u a <br /> ® Active 0 Passenger 0 Generator ® Outdoor <br /> O Q Closed Q Altered <br /> GPS Latitude Q Hauler ® Indoor <br /> O Q Inactive ® Truck <br /> Longitude — Q Planned ® OTR Q End-Use • Container <br /> Business Type(Fill all that apply) <br /> ® New Tire Dealer * Auto Repair Q Trucking Fleet Q Government Q Retreader Q Dismantler Q Tire Derived Fuel <br /> ® 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 14 CCR§18459-Responsible Entities Complying with Manifesting Requirements Date <br /> Q Q 14 CCR§18459.1 -Tire Program ID Number from CalRecycle <br /> 10 Q 14 CCR§18459.2.1 -Submittal of Comprehensive Trip Logs within 90 days (Required for NOV or EXT) N <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 /> f <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 <br /> In Compliance-No Violations o <br /> Q Q Othernn§ <br /> Comments Kul �i n� L3Ote. Ti!C. 1 r13n�r i' V1 J do'j' �Y11� <br /> ero n'W' n� SJ <br /> Inspection Form Included: Q n <br /> �� _3 �8 <br /> Comments Included: <br /> B in s Rep's Signature Phone Number Ins ctor's Signature Phone Number <br /> INSTRUCTIONS ON BACK Correct:* Incorrect: EXAM I P 62081 <br /> 1 2 3 <br /> White Copy:CalRecycle Yellow Copy:Operator Pink Copy: © ■ <br />