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Waste Tire S rey & Inspection Repor Inspection Report Number <br /> State of California <br /> Cal Recycle ( I 1 - 1226513 <br /> CalRecycle 181(Rev.10/10) <br /> (Cal Survey Form - Page 1 <br /> Dept.of Resources Recycling and Recovery(CalRecycle( <br /> Part A-Survey _ BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- / 2 Inspection Type(Fill one) <br /> Site Suffix: 6 3 0 2 1 J b ® Routine Q Re-inspection Q Referral Q Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier: - Q CHP Q CalRecycle Q Complaint Q Educational Visit Q Other <br /> Busines <br /> s or Facility Name <br /> JJ f ) Inspected By Inspector <br /> Physical Address ✓ 1�7 Ct - C7 ! <br /> OvrC.4v �( . <br /> Inspection Date <br /> �I �3o [ <br /> rte" �� � Time In Time Out <br /> Business Rep Title J 0 AM i ' 0 AM <br /> 0 PM f 0 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 /> 4— ® Active Q Passenger ® Generator Q Outdoor <br /> Q Closed Q Altered <br /> GPS Latitude 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 ® 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 I ENFORCEMENT STATUS <br /> V A HAULING AND MANIFEST REOUIREMENTS" <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 /> Q Q 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 <br /> Q Q 14 CCR§18459.2.1 -Submittal of Comprehensive Trip Logs within 90 days (Required for NOV or EXE N <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 /> f <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 /> 4-- C f it <br /> Inspection Form Included: Q <br /> Comments Included: (a <br /> Business Rep's Signature Phone Number Inspector's Signature Phone Number <br /> INSTRUCTIONS ON BACK [Correct:I, Incorrect: / EXAMPLE 1 2 3 62081 <br /> White Copy:CalRecycle Yellow Copy:Operator Pink Copy:LEA <br />