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Waste Tire Survey & Inspection Report Inspection Report Number <br /> CalRecycle State of cl181California 11 - 1226610 <br /> CalRecycle 181(Rev.10/10) Survey Form - Page 1 <br /> Dept of Resources Recycling and Recovery(CalRecycle) BLUE OR BLACK INK P E N <br /> Part A-Survey <br /> __ __ <br /> Business Profile Inspection Details <br /> TPID- L' Inspection Type(Fill one) <br /> Site Suffix: �1 0 l 13 � ® Routine Q Re-inspection Q Referral Q Observation <br /> Local C If Referral,choose referral type(Fill one) <br /> Identifier: Sa.r� � �� C Q CHP Q CalRecycle Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name Inspected By Inspector <br /> Physical Address t ��-C�✓1c=� <br /> Inspection Date / j <br /> 6A q5�qLlo Time In Time Out <br /> Business Rep Title O AM O AM <br /> I • d QPM ® PM <br /> 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) '� ® Active Q Passenger ® Generator Q Outdoor <br /> o Q Closed Q Altered <br /> GPS Latitude Q Hauler &lndoor <br /> o Q Inactive ® Truck <br /> Longitude - Q Planned i OTR Q End-Use Q Container <br /> Business Type(Fill all that apply) <br /> Q New Tire Dealer Q 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 0 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 /> Q Q 14 CCR§18459-Responsible Entities Complying with Manifesting Requirements Date m / <br /> m N <br /> Q Q 14 CCR§18459.1 -Tire Program ID Number from CalRecycle <br /> (Required for NOV or EXn a <br /> Q Q 14 CCR§18459.2.1 -Submittal of Comprehensive Trip Logs within 90 days a <br /> N <br /> Q Q 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 <br /> Q Referred/CalRecycle Enforcement 2 <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 N <br /> �� ✓JL!'11 CL -- <br /> Inspection Form Included: Q <br /> Comments Included: Bus ness Signature Phone Number p to Si ture Phone Number <br /> 62081 <br /> INSTRUCTIONS ON BACK Correct: Incorrect: � �/ E X A L E 1 2 '.3 ® ■ <br /> 0 <br /> White Copy:CalRecycle Yellow Copy:Operator Pink Co y: <br />