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Inspection Report Number <br /> � <br /> 02 Waste Tire Survey & Inspection Rep � <br /> CalRecycle State of California I 1 - 1176718 <br /> CalRecycle181(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: ' 3 5 oz57 I A Routine Q Re-inspection Q Referral Q Observation <br /> Local <br /> I If Referral,choose referral type(Fill one) <br /> Identifier: a{� V O (� C( n� Q CHP Q CalRecycle Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name Inspected By Inspector <br /> V"rA ("4 (� ��1� <br /> Physical Address <br /> Inspection Date ( / 0 5 I <br /> Time In Time Out J <br /> Business Rep TitleO AM O AM <br /> a 5 0 ®PM � � `/ O PM <br /> 1211 H Pelf1sOperational Status Tire Type Business Role Storage Type <br /> ! (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> Tire Count (Whole/PTE) , 1 <br /> ® Active ® Passenger ® Generator Q Outdoor <br /> Q Closed Q Altered <br /> GPS Latitude Q Hauler ® Indoor <br /> o Q Inactive Q Truck <br /> Longitude - Q Planned Q OTR Q End-Use Q Container <br /> Business Type(Fill all that apply) <br /> Q New Tire Dealer ® Auto Repair Q 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 CIm bev Le,- <br /> Part B - Inspection of Waste Tire Dealer, Generator, Hauler and End-Use Facility ENFORCEMENT STATUS <br /> V A HAULING AND MANIFEST REQUIREMENTS ------� 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 /> (Required for NOV or EX <br /> Q Q E <br /> 14 CCR§18459.2.1 -Submittal of Comprehensive Trip Logs within 90 days <br /> Q Q 14 CCR§18459.3-Retention of Comprehensive Trip Logs for 3 years <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 O 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators <br /> in Compliance-No Violations o <br /> Q Q Other:§ <br /> 1 f <br /> 1 <br /> Comments <br /> n �� <br /> No U;d "Osl_(, _6S c0c_)-S C IS)%fn - — <br /> Inspection Form Included: Q C, - <br /> Comments Inc <br /> ® Busin s Rep's Signature Phone Number InspeV"�,gnatu <br /> rrr's - one Number <br /> - 62081 <br /> INSTRUCTIONS ON BACK Correct:* Incorrect: � E X A1 2 3White Copy:CalRecycle Yellow Copy:Operator Pink © ■ <br />