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Waste Tire Su,vey & Inspection Report 'Inspection Report Number <br /> te of <br /> CalRecycle CaaRecyclelifornia 181(Rev.10/10) — 01210530 <br /> Dept.of Resources Recycling and Recovery(CalRecycle) Su rvey Form - Page 1 I 1 <br /> Part A-Survey BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- Inspection� I � � � _ 0 1 Inspection Type(Fill one) <br /> Site Suffix: 10 Routine Q Re-inspection Q Referral Q Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier: Cj�� �0o1_9 Q CHP Q CalRecycle Q Complaint Q Educational Visit Q Other <br /> uta C��`� <br /> Business orFacility Name Inspected By Inspector <br /> uT <br /> Physsiiic I i Addre V:G�C O vX I • <br /> Inspection Date 1 / 2 O / 1 3 <br /> s�oc��ov� r 9s2o6 J <br /> Time In Time Out <br /> Business Rep Title C� U 0 AM 2 �l 0 AM <br /> �^OYY� �0 V L� 1 1 S O PM � � J �-/ QPM <br /> \ OV' �� 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 Q Outdoor <br /> Q Closed Q Altered <br /> GPS Latitude Q Hauler Q Indoor <br /> o Q Inactive Q Truck <br /> Longitude - Q Planned * OTR Q End-Use 0 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 A t CGsA .M 4,V\\_\e�V� <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 Q PRC§42951 -Waste Tire Hauler Registration and Transport of Tires Q Notice Of Violation Q Extension <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) 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 /> 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 ` UJG-S �`�� ��Y�S(�.QC �O� �t�wN *4o,5 <br /> Inspection Form Included: 01 22Comments Included: J ����-2`� � <br /> Bu mess Rep's S' n e -Number Inspe or's Signature Phone Number <br /> INSTRUCTIONS ON BACK Correct:6 Incorrect: 7X7079�]fjEjXjAjMjPjLjEj 1 2 3 62081 <br /> ■ White Copy:CalRecycle Yellow Copy:Operator Pink Copy:LEA ® 0 <br />