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Waste Tire Survey & Inspection Report Inspection Report Number <br /> CalRec cle State of California _ <br /> Y CalRecycle 181(Rev.10/10) Survey Form - Page 1 I1 1245261 <br /> Dept.of Resources Recycling and Recovery(CalRecycle) <br /> BLUE OR BLACK INK PEN <br /> Part A- Survey <br /> Business Profile Inspection Details <br /> TPID- N (� 1 Inspection Type(Fill one) <br /> Site Suffix: , 2 1 v I I* Routine Q Re-inspection Q Referral Q Observation <br /> Local /� If Referral,choose referral type(Fill one) <br /> Identifier: !„ate O Cog �)%Y\ Q CHP Q CalRecycle Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name — � Inspected By Inspector <br /> G'-'C' 7 khCc Q _ 1 O A -V��' V�` <br /> Physical Address -` l / <br /> 11-33 Ma��Cti e�r VA SSC <br /> �I 5 33o Inspection Date <br /> Time In Time Out <br /> Business Rep Title O AM O AM <br /> C,� �i`S 2- • S S dp PM 3 PM <br /> ' Operational Status Tire Type Business Role Storage Type <br /> t� <br /> Tire Count(Whole/PTE) (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> 'L '1 <br /> Active Q Passenger I*Generator Outdoor <br /> O Q Closed Q Altered <br /> GPS Latitude Q Hauler 0 Indoor 1,7 <br /> O Q Inactive * 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 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 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 m / m / m <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 <br /> (Required for NOV or EX7 N <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 /> f <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 0 In Compliance-No Violations o <br /> Q Q <br /> Other:§ }` <br /> Comments ih� \ Ne oVl cl 'Ls <br /> C'Y\ <br /> Inspection Form Included: Q (�AO i W-3Z q <br /> Comments Included. 0CN <br /> ` <br /> Business Rep's Signat re Phone Number Inspec is Signature Phone Number <br /> INSTRUCTIONS ON BACK rrect:� Incorrect: X � q EXAMPLE 1 2 3 62081 <br /> Co <br /> White Copy:CalRecycle Yellow Copy:Operator Pink Copy:LEA <br />