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Waste Tire Survey & Inspection Report inspection Report Number <br /> Cal Rec cle State of California ` <br /> Y CalRecycle 181(Rev.10/10) Survey Form - Page 1 I1 1226218 <br /> Dept.of Resources Recycling and Recovery(CalRecycle) <br /> Part A-Survey _ _ BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- �--, O _ Q I Inspection Type(Fill one) <br /> Site Suffix: ® Routine 0 Re-inspection 0 Referral 0 Observation <br /> LocalP If Referral,choose referral type(Fill one) <br /> 1 <br /> Identifier: Say J oa f U,n X11 ) 0 CHP 0 CalRecycle 0 Complaint 0 Educational Visit 0 Other <br /> Business or Facility Name Inspected By Inspector <br /> J .�_ <br /> Sim PI �� C _ <br /> y, <br /> Physical Address 3 � , ���U�l <br /> Inspection Date I / �) <br /> �0� CA G�ti�t <br /> Time In Time Out <br /> Business Rep Title r, ,l O AM O AM <br /> -- <br /> Operational Status Tire Type Business Role Storage Type <br /> Tire Count (Whole/PTE) I (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> 0 Active 0 Passenger 0 Generator b Outdoor <br /> 0 Closed 0 Altered <br /> GPS Latitude 0 Hauler 0 Indoor <br /> O 0 Inactive ® Truck <br /> Longitude - ® OTR End-Use Container <br /> 0 Planned <br /> Business Type(Fill all that apply) <br /> 0 New Tire Dealer 0 Auto Repair 0 Trucking Fleet 0 Government 0 Retreader 0 Dismantler 0 Tire Derived Fuel <br /> 0 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 <br /> 0 Notice Of Violation 0 Extension <br /> 0 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 /> 0 0 14 CCR§18459-Responsible Entities Complying with Manifesting Requirements Date m / m / m <br /> 0 16 14 CCR§18459.1 -Tire Program ID Number from CalRecycle Z <br /> 0 0 14 CCR§18459.2.1 -Submittal of Comprehensive Trip Logs within 90 days (Required for NOV or EXE N <br /> 0 0 14 CCR§18459.3-Retention of Comprehensive Trip Logs for 3 years o <br /> 0 0 14 CCR§18460.2-Manifest System Requirements for Registered Waste Tire Haulers 0 Referred/CalRecycle Enforcement <br /> Uj <br /> 0 0 14 CCR§18461 -Manifest System Requirements for Waste Tire End-Use Facilities W <br /> 0 0 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators ®In Compliance-No Violations o <br /> 0 0 Other:§ <br /> X1 • <br /> CommentsD'A IAO L0 <br /> Inspection Form Included: OL� <br /> Z06 <br /> Comments Included: I �� <br /> Business Rep's Signature Phone Number In pec is Signature Phone Number <br /> INSTRUCTIONS ON BACK Correct:* Incorrect: �j E X I A I I 112 13 62081 <br /> ■ White Copy:CalRecycle Yellow Copy:Operator Pink Copy L © . <br />