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Waste Tire Su. Bey & Inspection Report nspection Report Number <br /> Cal Recpcle State of California _ <br /> 7 CalRecycle 181(Rev.10/10) Survey Form - Page 1 11 1196536 <br /> Dept,of Resources Recycling and Recovery(calRecycle) <br /> Part A-Survey BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- d � in -tion Type(Fill one) <br /> Site Suffix: outlne 9 Re-inspection Q Referral Q Observation <br /> Local _ If Referral,choose referral type(Fill one) <br /> Identifier: � �UQ �� y, Q CHP Q CalRecycle Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name Inspected By Inspector <br /> Physical Address 39 MAJ T k3 <br /> 1500 -- <br /> Inspection Date <br /> Time In Time Out <br /> Business Rep Titlei O AM O AM <br /> l <br /> S O PM ! PM <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 /> ' ' 1 46 Active 0 Passenger 0 Generator ® Outdoor <br /> o Q Closed Q Altered <br /> GPS Latitude Q Hauler Q Indoor <br /> 0 Q Inactive 0 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 ® Trucking Fleet Q Government Q Retneader Q Dismantler Q Tire Derived Fuel <br /> Q Used Tire Dealer Q Auto Body Q Car Dealer Q Collection Q Crurnb 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. I Compliance Deadline <br /> PRC§42956-Registration/Decal in Vehicle <br /> Q Q 14 CCR§18459-Responsible Entities Complying with Manifesting Requirements I Date <br /> Q Q 14 CCR§18459.1 -Tire Program ID Number from CalRecyclb <br /> Q Q 14 CCR§18459.2.1 -Submittal of Comprehensive Trip Logs within 90 days (Required for NOV or EX7) <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 /> 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 <br /> o� <br /> V. stap_ e'\ C..Qt-cec\Q <br /> lVo \S�o�a��c�spc astp'S Co�ce.C� <br /> Inspection Form Included: Q 0� 32 l <br /> Comments Included: 0U <br /> Business Re 's Signature Phone Number Anspeor's Signature Phone Number <br /> M � <br /> -- <br /> INSTRUCTIONS ON BACK Correct:I. Incorrect: 7X*7y1jEjXjAjMjPjLjEj 1 2 3 62081 <br /> ® White Copy:CalRecycle Yellow Copy:Operator Pink Copy:LEA ® 0 <br />