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X. ................ ------- <br /> ............ ........ ....... -------- ------- <br /> OZ Waste Tire Survey & Inspection Report Inspection Report Number <br /> State of California <br /> Cdecycle CalRecycle 181(Rev.10/10) 11 - 1210487 <br /> Dept.of Resources Recycling and Recovery(CalRecycle) Survey Form - Page 1 <br /> ,art A-Survey BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- G Inspection Type(Fill one) <br /> Site Suffi - 10 Routine 0 Re-inspection _ 0 Referral 0 Observation <br /> LocalIf Referral,choose referral type(Fill one) <br /> Identifier: _,,Y0tvt1A1' n G0un 0 CHP 0 CalRecycle 0 Complaint 0 Educational Visit 0 Other <br /> Business or Facility Name Inspected By Inspector <br /> jcl"\i o <br /> Physical Address <br /> 13's C- ki A-vt <br /> Inspection Date ZL <br /> A,oa� cA SIA() <br /> Time In Time Out <br /> Business Rep Title 0 AM l AM <br /> o o( 0 PM OPM <br /> )i`\t- �A tk, 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 * Passenger 0 Generator 0 Outdoor <br /> O <br /> GPS Latitude 0 Closed 0 Altered 0 Hauler 0 Indoor <br /> 0 0 inactive 0 Truck <br /> Longitude 0 Planned 0 OTR 0 End-use 0 Container <br /> Business Type(Fill all that apply) <br /> New Tire Dealer 0 Auto Repair 0 Trucking Fleet 0 Government 0 Retreader 0 Dismantler 0 Tire Derived Fuel <br /> Used Tire Dealer 0 Auto Body 0 car Dealer 0 Collection -0 Crumb Rubber <br /> 0 Service Station 0 Hauler 0 Agriculture 0 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 Notice'Of Violation 0 Extension <br /> — 0 PRC§42951 -Waste Tire Hauler Registration and Transport of Tires <br /> 0 0 PRC§42953-Contracts with Registered Waste Tire Haulers. Compliance Deadline <br /> 0 0 PRC§42956-Registration/Decal in Vehicle <br /> 00 14 CCR§18459-Responsible Entities Complying with Manifesting Requirements Date F, I <br /> 0 0 14 CCR§18459.1 -Tire Program ID Number from CalRecycle <br /> 0 0 14 CCR§18459.2.1 -Submittal of Comprehensive Trip Logs within 90 days (Required for NOV or EX7) <br /> 0 0 14 CCR§18459.3-Retention of Comprehensive Trip Logs for 3 years. <br /> 0 0 14 CCR§18460.2-Manifest System Requirements for Registered Waste Tire Haulers 0 Referred CalRecycle EnforcementUj <br /> Uj <br /> 0 0 14 CCR§18461 -Manifest System Requirements for Waste Tire End-Use Facilities <br /> 0 0 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators 0 In Compliance-No Violations <br /> 0 0 Other:§ <br /> Comments <br /> ii11 <br /> Inspection Form Included: 0 <br /> Comments Included- <br /> *Busi.n Rep's Signature Phone Number pe�r's Signature Phone Number <br /> Correct:0 incorrect: XZ 2i) 62081 <br /> INSTRUCTIONS ON BACK VS� W �VjjEjXjAjM� PjLjEj 1112131 <br /> White Copy:CalRecycle Yellow Copy:Operator Pink Copy:LEA <br />