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1 <br /> Waste Tire Survey & Inspection R 'Port Inspection Report Numtier r <br /> Cdeccle state of California — <br /> Y CalRecycle 181(Rev.10/10) Survey Form - Page 1 I1 1210533 <br /> Dept.of Resources Recycling and Recovery(CalRecycle) <br /> r A-Survey BLUE OR BLACK INK PEN <br /> iess Profile Inspection Details <br /> 7NID- i r (, _7 _ O ` Inspection Type(Fill one) <br /> Site Suffix: I b `� * Routine . Q Re-inspection Q Referral Q Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier: 0.v1 J 4 p�pt ��^ C 0 VAy Q CHP Q CalRecycle Q Complaint Q Educational Visit Q Other <br /> Business or Facility Names l L Inspected By Inspector <br /> P��Address <br /> I�OV�n2 �2 CvZ C� 1 - 0 <br /> Physical Address <br /> 3© 2 <br /> n 9S Inspection Date / 2- 7 / I 3 <br /> S�C�� %2 Time In Time Out <br /> Business Rep Title ` (1 Q M 0 AM <br /> . PM 2`Z 0 PM <br /> Operational Statues 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 /> Q Active Q Passenger Q Generator Q Outdoor <br /> O 1* Closed Q Altered <br /> GPS Latitude Q Hauler Q Indoor <br /> O Q Inactive Q Truck <br /> Longitude - Q Planned Q OTR 0 End-Use Q Container <br /> Business"Type(Fill all that apply) <br /> Jew Tire Dealer Q Auto Repair Q Trucking Fleet Q Government Q Retreader Q Dismantler Q Tire Derived Fuel <br /> Used Tire Dealer Q Auto Body Q Car Dealer Q Collection Q Crumb Rubber <br /> Q Service Station Q Hauler Q Agriculture Q Shredder Q 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 /> Q 0 0 Notice Of Violation Q Extension <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 /> PRC§42956-Registration/Decal in Vehicle <br /> Q 0 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 N <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 o <br /> Q Q 14 CCR§18460.2-Manifest System Requirements for Registered Waste Tire Haulers Q Referred/CalRecycle Enforcement <br /> Q Q 14 CCR§18461 -Manifest System Requirements for Waste Tire End-Use Facilities <br /> Q 0 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators ®In Compliance No Violations o <br /> Q 1 Q 1 Other:§ <br /> Comments <br /> egg <br /> ...dpection Form Included: 0 A lAk <br /> Comments Included: <br /> Business Rep's Signature Phone Number Inspector's Signature Phone Number <br /> �( <br /> INSTRUCTIONS ON BACK Correct:0 Incorrect: �J EXAMPLE111213 62081 <br /> ■ White Copy:CalRecycle Yellow Copy:Operator Pink Copy:LEA ® ■ <br />