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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 1 11 - 1176762 <br /> Dept.of Resources Recycling and Recovery(CalRecycle) <br /> Ili P--t A -Survey__.____,__._ BLUE OR BLACK INK PEN <br /> ness Profile Inspection Details <br /> ow <br /> TPID- Inspection Type(Fill one) <br /> Site Suffix: ' y Q 3 O 1 ® Routine Q Re-inspection Q Referral Q Observation <br /> Local / }_ If Referral,choose referral type(Fill one) <br /> Identifier: ISC>`y1 (rt• l/g� l�e�l/✓l '+ �l Q CHP Q CalRecycle Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name ! Inspected By Inspector <br /> �1 f� <br /> Physical Address <br /> �� l 1 l r�Lm�JL/�G�(� (�J; Inspection Date <br /> C ` <br /> 1 CSC l Time In l Time Out L 1 I <br /> Business Rep t)rV� Titley ` 9 ® PM 1 40 PM <br /> �4ZCtlC�© i tl�NLcc ✓• <br /> Operational Status Tire Type Business Role Storage Type <br /> / (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> Tire Count(Whole/PTE) <br /> Q Active Q Pa/s�e,�er a Generator Q Outdoor <br /> O ® Closed Q Alterdd At /,& <br /> GPS Latitude Q Hauler I Q Indoor <br /> O Q Inactive Q Truck <br /> Longitude - Q Planned Q OTR Q End-Use Q Container <br /> Business Type(Fill all that apply) <br /> New Tire Dealer Q Auto Repair Q Trucking Fleet Q Government Q Retreader Q Dismantler Q Tire Derived Fuel <br /> U Used Tire Dealer Q Auto Body Q Car Dealer Q Collection 0 Crumb Rubber <br /> Q Service Station Q Hauler Q Agriculture Q Shredder ® Other <br /> Part B - Inspection of Waste Tire Dealer, Generator, Hauler and End-Use Facility ENFORCEMENT STATUS <br /> V A HAULING AND MANIFEST REQUIREMENTS 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 /> QQ 14 CCR§18459-Responsible Entities Complying with Manifesting Requirements Date FTI <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 /> Lu <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 <br /> in Compliance-No Violations o <br /> 010 Other:§ <br /> Comments <br /> Inspection Form Included: Q <br /> Comments Included: 'h-�- ----�— — <br /> Bu iness Rep's ' nature <br /> Pah o a Number Ase s ig at re Phone Number <br /> - PLE 1 2 3 62081 <br /> INSTRUCTIONS ON BACK Correct:- Incorrect: © ■ <br /> ■ White Copy:CalRecycle Yellow Copy:Operator Pink Copy:LEA <br />