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Waste Tire Survey & Inspection Report Inspection Report Number <br /> Stte of <br /> CalRecycle CalRecycleilia 181n(Rev.10/10) — ■ <br /> Dept.of Resources Recycling and Recovery(CalRecycle) <br /> Survey Form - Page 1 I1 1196722 <br /> P--+ A- Survey BLUE OR BLACK INK PEN <br /> less Profile Inspection Details <br /> }viD - O Inspection Type(Fill one) <br /> OSite Suffix: 1 0 Routine Q Re-inspection Q Referral Q Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier: 15lx1r\ Q CHP Q CalRecycle Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name Inspected By Inspector <br /> GL�� X0.1 a - 1 o ti <br /> Physical Address <br /> $2'r'c col,'�-'a` <br /> ` p ,5q Inspection Date � 1 / b S � 1 3 <br /> Time In Time Out <br /> Business Rep Title ' SoO AM , 2 : -Z d 0 AM <br /> PM 0 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 /> Q Active Q Pass ger Q Generator Q O;t or <br /> O 0 Closed Q Altered' I� N�� <br /> GPS Latitude Q Hauler 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 /> '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 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 /> 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 / 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 /> Q Q 14 CCR§18461 -Manifest System Requirements for Waste Tire End-Use Facilities W <br /> Q Q 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators •In Compliance-No Violations o <br /> Q 1 Q Other:§ <br /> Comments <br /> ...pection Form Included: Q _ 1, <br /> Comments Included: Cad/� `5� =1 <br /> Business h P'S&gnaturb Phone Number Inspec or's Signature Phone Number <br /> INSTRUCTIONS ON BACK Correct:0 Incorrect: ® � E X A M P L E 1112 3 62081 <br /> ■ White Copy:CalRecycle Yellow Copy:Operator Pink Copy:LEA © ■ <br />