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Waste Tire Survey & Inspection Report Inspection Report Number <br /> CalRecycle State of California _ 1 I 1 - 1226612 <br /> CalRecycle 181(Rev.10/10) Survey Form Page <br /> Dept.of Resources Recycling and Recovery(CalRecycle) BLUE OR BLACK INK PEN <br /> Part A-Surve — <br /> Business Profile inspection Details <br /> TPID- inspection Type(Fill one) <br /> Site Suffix: ( �} 3 V V ® Routine Q Re-inspection Q Referral Q Observation <br /> Local �vn If Referral,choose referral type(Fill one) <br /> Identifier: Q CHP Q CalRecycle Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name Inspected By Inspector <br /> Physical Address 0, 1 4,zyn <br /> o`Z <br /> J /I Inspection Date / Q z_Time In (� Time Out <br /> Business Rep Title ® AM ` . ®AM <br /> � J 0 PM 3 `-` O PM <br /> CL'� ((Y v����G� -- "` Operational 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) , j Vt Q IS Active ® Passenger 0 Generator V ® Outdoor <br /> o Q Closed Q Altered <br /> GPS Latitude Q Hauler Q Indoor <br /> o Q Inactive Q Truck <br /> Longitude - Q Planned Q OTR ® End-Use Q Container <br /> Business Type(Fill all that apply) <br /> Q Government Q Retreader Q Dismantler Q Tire Derived Fuel <br /> 0 New Tire Dealer Q Auto Repair Q Trucking Fleet <br /> it 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 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 /> QQ 14 CCR§18459-Responsible Entities Complying with Manifesting Requirements Date M / M / FF N <br /> Q Q 14 CCR§18459.1 -Tire Program ID Number from CalRecycle <br /> Q Q 14 CCR§ — (Required for NOV or EXT) ? <br /> 18459.2.1 -Submittal of Comprehensive Trip Logs within 90 days a <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 EnforcementS <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 <br /> Q Q Other:§ <br /> Comments _ <br /> V <br /> Inspection Form Included: Q 7 <br /> Comments Included: <br /> Business Rep's Igna ure Phone Number In, a or' i ure Phone Number <br /> 62081 <br /> INSTRUCTIONS ON BACK Correct:* Incorrect: `X A M L E 1 2 3 <br /> ■ White Copy:CalRecycle Yellow Copy:operator Pink Cop :L ® ■ <br />