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0 Waste Tire SAey & Inspection Reporpinspection Report Number <br /> calRec cle State of California <br /> Y CalRecycle 181(Rev.10/10) SUrVey Fornl - Page 1 I 1 1229924 <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� Inspection Type(Fill one) <br /> Site Suffix: " 40 Routine Q Re-inspection Q Referral Q Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier. e>C`-4� r c V'1 n Q CHP Q CalRecycle Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name " q Inspected By Inspector <br /> S�zE 2 T,c-e_, T\j <br /> Physical Address <br /> X21 Main s� ' <br /> Inspection Date D I / Z z / , S <br /> Time In Time Out <br /> ✓ <br /> Business Rep Title 50 AM U 0 AM <br /> _ lJ 0 PM + O 0 PM <br /> k"� es O <br /> Operational Status Tire Type Business Role Storage Type <br /> Tire Count (Whol PT Y O /_ 4j (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> 1 (� o 0 Active 0 Passenger 0 Generator 0 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 0 Container <br /> Business Type(Fill all that apply) <br /> +0 New Tire Dealer Q 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 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 EJC N <br /> Q O 14 CCR§18459.3-Retention of Comprehensive Trip Logs for 3 years <br /> Q O 14 CCR§18460.2-Manifest System Requirements for Registered Waste Tire Haulers. Q Referred/CalRecycle Enforcement <br /> LU <br /> Q O 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�� -- r e <br /> MAOS 8(' rA <br /> Inspection Form�nc <br /> ncluded: Q <br /> / <br /> Comments luded: <br /> usiness ignat Phone Number Inspe or's Signature Phone Number <br /> INSTRUCTIONS ON BACK I Correct: Incorrect: X � EXAMPLE 1112 3 62081 <br /> White Copy:CalRecycle Yellow Copy:Operator Pink Copy:LEA <br />