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Waste Tire Survey & Inspection Report Inspection Report Number <br /> CalRec ole State of California <br /> Y CalRecycle 181(Rev.10/10) Survey Form - Page 1 I1 1245015 <br /> Dept.of Resources Recycling and Recovery(CalRecycle) <br /> Part A- Survey BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- Q Inspection Type(Fill one) <br /> Site Suffix: I l '0 Routine Q Re-inspection Q Referral Q Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier: `� ,� dV Q CHP Q CalRecycle Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name JJ Inspected By Inspector <br /> 1-6vv.e- dk ��zZ _ l ► MATTv <br /> Physical Address <br /> Inspection Date C' S <br /> Time In Time Out <br /> Business Rep Title 0 AM 0 AM <br /> ' 1 t PM O 0 PM <br /> ��ve 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(U Q Active Q <br /> O Paer Q Ge r 0X <br /> GPS Latitude * Closed Q AltsQ Hauler Q Indoor <br /> O Q Inactive Q Truck <br /> Longitude - Q End-Use Q Container <br /> Q Planned Q OTR <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 a Other Qe\-04` <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 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 <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 <br /> Q Q 14 CCR§18460.2-Manifest System Requirements for Registered Waste Tire Haulers Q Referred/CalRecycle Enforcement <br /> ui <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 e In Compliance-No Violations o <br /> Q Q Other:§ <br /> Comments— 1 ( \ UJ4� n <br /> �4n►�y L\ �Vs2_Q �J�C� TO� V�e <br /> �jb�c��iorg n f- 20 5 c5� �o✓\CefV� <br /> � ccGs� <br /> InspectioL' 62081 ncluded: Q ?0q-q & 3zQ� <br /> CoIncluded: Q W J CJ, <br /> usin ss s nature Phone Number Inspec or's Signature Phone Number <br /> INSTRUCTIONS ON BACK Correct: Incorrect: L E 1 2 3 <br /> ■ White Copy:CalRecycle Yellow Copy:Operator Pink Copy:LEA <br />