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Waste Tire Su ey & Inspection Report Inspection Report Number <br /> � <br /> CalRecycle State <br /> taiforn <br /> CalReof Calcle 181 iRev.10/10) — <br /> Dept.of Resources Recycling and Recovery(CalRecycle) <br /> Survey Fora - Page 1 I1 1210425 <br /> Part A-Survey BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- O Inspection Type(Fill one) <br /> Site Suffix: L "l l `� ® Routine Q Re-inspection Q Referral Q Observation <br /> Local ] If Referral,choose referral type(Fill one) <br /> Identifier. �CA.n J o ta,G V1 j �t,�n ] Q CHP Q CalRecycle Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name { Inspected By Inspector <br /> �V INS f e It <br /> Physical Address ) Cs CUITC) <br /> (A � s ZO5 Inspection Date "7 <br /> O L�+ 0^ Time In Time Outl <br /> Business Rep Title AM <br /> ), , S * PM v � U <br /> V PM <br /> 6SU 1kr, [P Anu,S,-_, <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 /> ' Active Passenger ® Generator 40 Outdoor <br /> Q Closed Q Altered <br /> GPS Latitude Q Hauler Q Indoor <br /> O Q Inactive Q Truck <br /> Longitude - Q Planned Q OTR ® 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 /> ® 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 /> 40Q Q - 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 Q 14 CCR§18459-Responsible Entities Complying with Manifesting Requirements Date® / Mjq 13 <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 <br /> 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 Q In Compliance-No Violations o <br /> Q Q Other:§ - <br /> Comments V�� �-1m q'rl(� <br /> D �J rN 14 CA <br /> C2.� Cts�rrt ll 3 r <br /> Inspection Form Included: Q <br /> Comments Included: IOQSOcsr aArnt <br /> Business Rep's Signature Phone Number Inspe is Signature hone Number <br /> INSTRUCTIONS ON BACK I Correct:0 Incorrect: M 7E X A L 1 2 3 62081 <br /> ■ White Copy:CalRecycle Yellow Copy:Operator Pin Co y: © ■ <br />