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Waste Tire Survey & Inspection Report Inspection Report Number <br /> Cdeccle State of California — <br /> Y CalRecycle 181{Rev.10/10) Survey Form - Page 1 11 1230134 <br /> Dept.of Resources Recycling and Recovery(calRecycle) <br /> Part A- Survey _ BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- + Inspection Type(Fill one) <br /> Site Suffix: I z, ! $ p , 1 Routine 0 Re-inspection 0 Referral 0 Observation <br /> Local / If Referral,choose referral type(Fill one) <br /> Identifier: Un Tya'j tA,,n (,(91^f1N 0 CHP 0 CalRecycle 0 Complaint 0 Educational Visit 0 Other <br /> Business or Facility Name Inspected By Inspector <br /> Tor ad v CPhyAddress , 7J b <br /> '3 51, <br /> Inspection Date <br /> AL�rn f v GA �ZL(� <br /> Time In Time Out <br /> Business Rept ( 1 TitleL ` 1 dL : v O AM O AM <br /> 0 PM � ® 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 Passsee�ger 0 Generator 0 Ou <br /> tdoor <br /> O 0 Closed 0 AltNreTil N )GPS Latitude A 0 Hauler 0 <br /> 0 0 Inactive 0 Truck <br /> Longitude - 0 Planned 0 OTR 0 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 ® Agriculture 0 Shredder 0 Other <br /> Part B - Inspection of Waste Tire Dealer, Generator, Hauler and End-Use Facility ENFORCEMENT STATUS <br /> V A HAULING AND MANIFEST REQUIREMENTS <br /> 0 Notice Of Violation 0 Extension <br /> 0 0 <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 / m / 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 EXn N <br /> 0 0 14 CCR§18459.3-Retention of Comprehensive Trip Logs for 3 years <br /> 0 0 14 CCR§18460.2-Manifest System Requirements for Registered Waste Tire Haulers 0 Referred/calRecycle Enforcement <br /> LU <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 , /" fin j4L gin <br /> �o ; tis n CZA l <br /> Inspection Form Included: 0 _ <br /> AU <br /> Comments Included: 0____ 11,1 nOJI <br /> Business Rep's Signature Phone Number Inspe isSignature Phone Number <br /> INSTRUCTIONS ON BACK Correct: Incorrect: [EIXIAI E 1 2 3 62081 <br /> White Copy:CalRecycle Yellow Copy:Operator Pink Cop :LEA <br />