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Waste Tire Sup vey & Inspection Report Inspection Report Number 01 <br /> CalRecycle State of California <br /> CalRecycle 181,(Rev.10/10) Survey Form - Rage 1 11 12 3 0 0 5 <br /> Dept of Resources Recycling and Recovery(CalRecycle) <br /> Survey <br /> BLACK INK PEN <br /> Part A-Survey <br /> Business Profile Inspection Details <br /> TPID- Q Inspection Type(Fill one) <br /> Site Suffix: I , Routine Q Re-inspection Q Referral Q Observation <br /> LocalIf Referral,choose referral type(Fill one) <br /> Identifier: <br /> 0.,m J r\ C6�r. Q CHP Q CalRecycle Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name Inspected By Inspector <br /> 70Lq-a. N�&�s 'Y NN-V,4LIC-,Li _t J `O\C • 9 _ 10 B <br /> Physical Address <br /> Inspection Date a S <br /> SVc.ceNdY. <br /> Time In Time Out <br /> Business Rep Titler U e 3 S O AM <br /> PM o 1 O PM <br /> PM <br /> ��RVr ,�VYhQLh \ I <br /> Operational Status Tire Type Business Role Storage Type <br /> Tire Count (Whole/PTE) (Fill one only) (FII all that apply) (Fill all that apply) (Fill all that apply) <br /> ®Active Q Passenger 0 Generator Q Outdoor <br /> O Q Closed Q Altered N !A <br /> GPS Latitude Q Hauler Q Indoor <br /> O Q Inactive Q Truck <br /> Longitude - Q Planned A OTR Q End-Use Q 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 ® Other ,1��2�(` <br /> Part B- Inspection of Waste Tire Dealer, Generator, Hauler and End-Use Facility ENFORCEMENT STATUS <br /> V A I HAULING AND MANIFEST REQUIREMENTS <br /> Q Q Notice Of Violation Q Extension <br /> Q <br /> 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 /> (Required for NOV or EXT) <br /> Q Q 14 CCR§18459.2.1 -Submittal of Comprehensive Trip Logs within 90 days 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 /> uj <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 /> Comments <br /> Ytw►�C�Qie �C7 V�T��� �gjfi� �� t�1S�JQ C��d� �(�YAP Q_1"�_ <br /> Inspection Form Included: Q go4 <br /> Comments Included: usiness Rep's nature PhoLNumber Inspe or's Signat Phone Number <br /> INSTRUCTIONS ON BACK Correct:0 Incorrect: - 4 EXAM P L E 1 2 3 62081 <br /> ■ White Copy:CalRecycle Yellow Copy:Operator Pink Copy:LEA ® ■ <br />