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02 Waste Tire Survey & Inspection Repoli Inspection Report Number <br /> CalRecycle State of California I 1 - 1226666 <br /> CalRecycle 181(Rev.10/10) Survey Form - Page 1 <br /> Dept.of Resources Recycling and Recovery(CalRecycle) BLUE OR BLACK INK PEN <br /> Part A-Survey- ----- <br /> Business Profile Inspection Details <br /> TPID- Inspection Type(Fill one) <br /> Site Suffix: ' ` 9 O 1! Routine Q Re-inspection Q Referral Q Observation <br /> Local ` r If Referral,choose referral type(Fill one) <br /> Identifier: Jdol �OU�(/(t n `U�� Q CHP Q CalRecycle Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name (r Inspected By Inspector <br /> Physical Address <br /> N . W ;Ison w� 1 <br /> ( ' �los Inspection Date <br /> Time In Time Out <br /> Business Rep Title I 0 O AM -7 J (� <br /> n of ,•� O AM <br /> O PM PM <br /> Vu Mut\w vtr <br /> Operational Status Tire Type Business Role Storage Type <br /> 1 (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> Tire Count(Whole/PTE) , 1•r $ Active ® Passenger ® Generator ® Outdoor <br /> Q Closed Q Altered <br /> GPS Latitude Q Hauler ® Indoor <br /> 0 Q Inactive ®Truck <br /> Longitude - Q Planned Q OTR Q End-Use ® 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 /> 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 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 / [T] / M m / N <br /> Q Q 14 CCR§18459.1 -Tire Program ID Number from CalRecycle <br /> (Required for NOV or EXT N <br /> Q Q 14 CCR§18459.2.1 -Submittal of Comprehensive Trip Logs within 90 days v <br /> Q Q 14 CCR§18459.3-Retention of Comprehensive Trip Logs for 3 years <br /> Q Q 14 CCR§18460.2 Q Referred/CalRecycle Enforcement <br /> Manifest System Requirements for Registered Waste Tire Haulers 2 <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 ®In Compliance-No Violations o <br /> Q Q Other:§ 11 1 <br /> Comments �o tJ� \f� 'I Ins lin �U�119t�1_nom. <br /> W(XS oo�,ezl <br /> NQ V10 ki 0f carec�s crF_ �c�v'n. <br /> Inspection Form Included: <br /> Comments Included: ®� v"�— - - � � - <br /> Business Rep's Signatu Phone Number Ins tor's Signature Phone Number <br /> — — — 62081 <br /> INSTRUCTIONS ON BACK Correct:4 Incorrect: y/ � E X A P 1 2 3 <br /> White Copy:CalRecycle Yellow Copy:Operator Pink Co A © ■ <br /> ■ <br />