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Waste Tire Su. ,iey & Inspection Report inspection Report Number <br /> CalRec cle State of California — <br /> Y CalRecycle 181(Rev.10/10) Survey Form - Page 1 11 1210394 <br /> Dept of Resources Recycling and Recovery(CalRecycle) <br /> Part A-Survey BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- , t O 1 9 © Inspection Type(Fill one) <br /> Site Suffix: "1 l 0 Routine Q Re-inspection Q Referral Q Observation <br /> Localr�' I If Referral,choose referral type(Fill one) <br /> Identifier: C'yX ✓0CLV' ,/� y` Q CHP Q CalRecycle Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name (( Inspected By Inspector <br /> USA-\'k `Ccs,\e `e,S �� Ce�n�c'a-@, p� l O I1 J <br /> Physical Add&ss L - ���V <br /> Inspection Date <br /> Time In Time Out <br /> Business Rep Title AM <br /> r AM �,\ SAM <br /> O PM 1 V O Q 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 /> Active Q Passenger ® Generator 16 Outdoor <br /> O <br /> GPS Latitude Q Closed Q Altered <br /> Q Hauler Q Indoor <br /> O 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 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 <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. Compliance Deadline <br /> 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 N <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 <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 40 In Compliance-No Violations o <br /> Q Q Other:§ <br /> Comments on k- z S t Qnl- kl&j N <br /> k�Q c Wc�S odd <br /> Inspection Form Included: QI— C p� <br /> Comments Included: ® � -gy� ` _qb D'3ze 4 <br /> sines ep' ignature Phone Number Inspect is Signature Phone Number <br /> �,( 62081 <br /> INSTRUCTIONS ON BACK Correct:® Incorrect: zs� 1 NJ E X A M P L E 1 2 3 <br /> White Copy:CalRecycle Yellow Copy:Operator Pink Copy:LEA <br />