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R <br /> Waste Tire Survey & Inspection Report Inspection Report Number . <br /> CalRecycle State of California 11 - 1226601 <br /> CalRecycle 181(Rev.10/10) Survey Form - Page 1 <br /> Dept.of Resources Recycling and Recovery(CalRecycle) BLUE OR BLACK INK PEN <br /> Part A-Survey —_. _—_ <br /> Business Profile Inspection Details <br /> TPID- ` Inspection Type(Fill one) <br /> Site Suffix: I 6 g �7 �.] / Q 0 Routine Q Re-inspection Q Referral Q Observation <br /> Local IfReferral,chooseree Fill one) <br /> Identifier: � QCHP QCalRecycle0Comptaint Q Educational Visit <br /> Other <br /> Business or Facility Name Inspected/By 7 / Inspector <br /> 61 f� S CIIIV �Z1 (�f' Y -�-%� �l A, <br /> Physio Address L/ Yn 16 <br /> Inspection Date <br /> / c-X C✓ <br /> Time In Time Out <br /> Business Rep Title Q AM ) 1 AM <br /> L' 0 P l l Z 0 P <br /> - Imo' Operational Status Tire Type Business Role Storage Type <br /> r/ (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> Tire Count (Whole/PTE) (/ <br /> ® Active 40 Passenger ®'Generator Outdoor <br /> O Q Closed Q Altered <br /> GPS Latitude Q Hauler Q 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 /> New Tire Dealer 0 Auto Repair Q Trucking Fleet Q Government Q Retreader Q Dismantler Q Tire Derived Fuel <br /> 0 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 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 EXT) <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 /> W <br /> Q Q 14 CCR§18461 -Manifest System Requirements for Waste Tire End-Use Facilities <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 /> 4 <br /> Comments /'� ►//� <br /> (l <br /> Inspection Form Included: Q <br /> rtfumber <br /> *sSi <br /> Comments Included: PhPhone Number <br /> 62081 <br /> INSTRUCTIONS ON BACK Correct:* Incorrect23White Copy:CalRecycle Yellow Copy:Operator <br />