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Waste Tire Survey & Inspection Reporll,. r Inspection Report Number <br /> State of <br /> CalRecycle CalRecyclel181(Rev.10/10) - 1226515 <br /> • <br /> Dept.of Resources Recycling and Recovery(CalRecycle) <br /> Survey Form - Page 1 I1 <br /> Part A-Survey <br /> BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- i / q 1 1 O I Inspection Type(Fill one) <br /> Site Suffix: I l0 1 "I * Routine Q Re-inspection Q Referral Q Observation <br /> Local r^ I If Referral,choose referral type(Fill one) <br /> Identifier: 5 Q CHP Q CalRecycle Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name 1 "I Inspected By Inspector <br /> Physical Address 3 ( 0 <br /> { 6o6 <br /> �5�� Inspection Date 1 V / � / I 1 <br /> A 4C C4_11G A Time In Time Out <br /> Business Rep Title /, 0 AM �1 0 7� 0 AM <br /> p1k Vt � �Cf� in a)kr V v ® PM J . V C/ e PM <br /> aw Ck r {Y1 C'. <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 /> N ® Active 40 Passenger is Generator Q Outdoor <br /> O Q Closed Q Altered <br /> GPS Latitude Q Hauler If Indoor <br /> O Q Inactive Q Truck <br /> Longitude — Q Planned Q OTR Q End-Use Q Container <br /> Business Type(Fill all that apply) <br /> ® 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 /> ®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 t <br /> Q O 14 CCR§18459-Responsible Entities Complying with Manifesting Requirements Date <br /> Q Q 14 CCR§18459.1 -Tire Program ID Number from CalRecycle '3 <br /> Q Q 14 CCR§18459.2.1 -Submittal of Comprehensive Trip Logs within 90 days (Required for NOV or EX7J <br /> Q O 14 CCR§18459.3-Retention of Comprehensive Trip Logs for 3 years o <br /> Q 14 CCR§18460.2-Manifest System Requirements for Registered Waste Tire Haulers Q Referred/CalRecycle Enforcement <br /> Q Q 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 Q In Compliance-No Violations o <br /> Q Q Other:§ <br /> Comments <br /> Inspection Form Included: Q <br /> Comments Included: ® <br /> Business Rep's Signature Phone Number Inspe or's Signature Phone Number <br /> INSTRUCTIONS ON BACK Correct:0 Incorrect: EXAM L i 2 3 62081 <br /> ■ White Copy:CalRecycle Yellow Copy:Operator Pink Cop L ® ■ <br />