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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 I1 1230080 <br /> Dept.of Resources Recycling and Recovery(CalRecycle) <br /> Part A- Survey BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- ' 7 _ O Inspection Type(Fill one) <br /> Site Suffix: `� 11111, Routine 0 Re-inspection 0 Referral 0 Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier: c � OCHP OCaIRecvcle 0 Complaint OEducational Visit OOther <br /> Business or Facility Name Inspected By Inspector <br /> J Q-0� <br /> Physical Address I V <br /> Inspection Date O � � Z 7 � 15 <br /> SC' 52'1-2- Time In Time Out <br /> Business Rep Title O O *AM P 0 AM <br /> 0 PM {vim Q 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 /> 0 Active 0 Passenger 0 Generator 0 Outd or <br /> O Closed 0 Altere ���� A// <br /> GPS <br /> Latitude ® JA O Haul4r 0 Indo' <br /> O 0 Inactive 0 Truck <br /> Longitude — 0 Planned 0 OTR O End-Use 0 Container <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 •Other �QSi� C2r <br /> Part B - Inspection of Waste Tire Dealer, Generator, Hauler and End-Use Facility ENFORCEMENT STATUS <br /> V A HAULING AND MANIFEST REQUIREMENTS <br /> O O § - Q Notice Of Violation Q Extension <br /> PRC 42951 Waste Tire Hauler Registration and Transport of Tires <br /> 0 0 PRC§42953-Contracts with Registered Waste Tire Haulers. Compliance Deadline <br /> PRC§42956-Registration/Decal in Vehicle <br /> 0 0 14 CCR§18459-Responsible Entities Complying with Manifesting Requirements Date m <br /> 0 0 14 CCR§18459.1 -Tire Program ID Number from CalRecycle <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 /> Lu <br /> W <br /> 0 0 14 CCR§18461 -Manifest System Requirements for Waste Tire End-Use Facilities <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 /> Comments, X <br /> VJG 5 T <br /> �C, \.'i �� G C NRQ!1-7Sor�7sc rev <br /> Inspection Form Included: 0 <br /> Comments Included: 1101, <br /> Business Rep's Signature Phone Number Inspect is Signature Phone Number <br /> INSTRUCTIONS ON BACK [Correct:0 Incorrect: X E X A M P L EJ 1 2 3 62081 <br /> White Copy:CalRecycle Yellow Copy:Operator Pink Copy:LEA <br />