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Waste Tire Survey & Inspection Report Inspection Report Numberof <br /> ■ <br /> CalRecycle CaalRecyclete llia 181n(Rev.10/10) — <br /> Dept,of Resources Recycling and Recovery(CalRecycle) <br /> Survey Form - Page 1 I1 1196720 <br /> P 'A- Survey BLUE OR BLACK INK PEN <br /> less Profile Inspection Details <br /> 'I t-ID- Inspection Type(Fill one) <br /> Site Suffix: I �j g l 2- O 9 Routine Q Re-inspection Q Referral Q Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier: S�.^ �00 91 h V �F Q CHP Q CalRecycle Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name Inspected By Inspector <br /> V_tl�/ CoV,.5�r-v c_�v o VA <br /> Physical Address 3 9 <br /> Inspection Date 1 1 � b 7 <br /> Time In Time Out <br /> Business Rep \ TitleO AM O AM <br /> 2 S O . 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 Passeer Q Gen��r QNuttdoor <br /> O •Closed Q AltereN N /A <br /> GPS Latitude O 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 /> lew 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 I* Other us:"S4_ykr-C_/tw— <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 <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 /> 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 EXT) <br /> Q Q 14 CCR§18459.3-Retention of Comprehensive Trip Logs for 3 years <br /> 0 <br /> Q Q 14 CCR§18460.2-Manifest System Requirements for Registered Waste Tire Haulers Q Referred/CalRecycle Enforcement <br /> 2 <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 Q Other:§ <br /> Comments �ti�U� Cotes `•CQ_ W 0$��"t'�r'� �`��p�'�o�/�. `�S —�� <br /> act.�cC_ Ux�� \Av\� <br /> ­.pection Form Included: Q <br /> Comments Included: 0 ,,7( I"�OD" JZO 1 <br /> Business Rep's Signature Phone Number Inspec'tor's Signature Phone Number <br /> �,( - <br /> INSTRUCTIONS ON BACK Correct:4D Incorrect: N NJ JEX A M P L E 1 2 3 62081 <br /> ■ White Copy:CalRecycle Yellow Copy:Operator Pink Copy:LEA <br />