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Waste Tire Sus vey, & hspec on Re on Inspection Report Number <br /> Stte of <br /> calRecycle CaaRecyclel181(IRev.10/10) m <br /> Dept.of Resources Recycling and Recovery(CalRecycle) <br /> Survey Fora Page I11242194 <br /> Part A-Survey _ BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- Inspection Type(Fill one) <br /> Site Suffix: Routine Q Re-inspection Q Referral Q Observation <br /> Local �Q I, If Referral,choose referral type(Fill one) <br /> Identifier: �/� �� ��� 0 CHP Q CalRecycle Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name Inspected By Inspector <br /> ic��,l�✓�' � 155�/ _ <br /> Physical Address <br /> 3 �VIA vim- 4-4-X <br /> 1Inspection Date <br /> 6A Q5�ZI'1_ Time In Time Out <br /> Business Rep Title8 AM ®AM <br /> i <br /> 1 0 • 4t 0 Q PM T 1 I O PM <br /> Svc- Yl G <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 /> ' ' ®Active lb Passenger 0 Generator Q Outdoor <br /> O Q Closed Q Altered <br /> ��� Latitude Q Hauler ®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 /> S 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 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 /> PRC§42956-Registration/Decal in Vehicle <br /> Q Q 14 CCR§18459-Responsible Entities Complying with Manifesting Requirements- Date <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 (Required for NOV or EXE N <br /> a <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 /> 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 •In Compliance-No Violations o <br /> Q Q Other:§ <br /> Comments <br /> u <br /> Inspection Form Included: Q ,, r <br /> Comments Included: ® l� uo <br /> si s R p' ignature Phone Number Ins o 's Sig Phone Number <br /> INSTRUCTIONS O BACK Correct:* Incorrect: E X A 111213 <br /> 2 s2os1 <br /> ■ White Copy:CalRecycle Yellow Copy:Operator Pink Copy.L <br />