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Waste Tire Su. ✓ey & Inspection Report Inspection Report Number ■ <br /> CalRecycle CaaStte of Recyclel'fornia 181(Rev.10/10) <br /> Dept.of Resources Recycling and Recovery(CalRecycle) Survey Form - Page 1 11 - 1196251 <br /> Part A- Survey BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- � � Inspection Type(Fill one) <br /> Site Suffix: _1 '0 Routine Q Re-inspection Q Referral Q Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier: ��„� O CHP O CalRecycle Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name Inspected By Inspector <br /> Physical Address <br /> t5 3g `:. <br /> Inspection Date <br /> S� C g52c5 <br /> Time In Time Out <br /> Business Rep Title Q AM 2Q AM <br /> / 2 2 0 PM 7 O PM <br /> Operational Status Tire Type Business Role Storage Type <br /> Tire Count(WholPTE) 1 O (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> 1 * Active 0 Passenger 0 Generator 0 Outdoor <br /> Q Closed Q Altered <br /> GPS Latitude ® Hauler 0 Indoor <br /> 0 Q Inactive ! Truck <br /> Longitude — 0 Planned Q OTR • End-Use 0 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 O Crumb Rubber <br /> Q Service Station * 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 Notice Of Violation 0 Extension <br /> O O PRC§42951 -Waste Tire Hauler Registration and Transport of Tires <br /> O O PRC§42953-Contracts with Registered Waste Tire Haulers. Compliance Deadline <br /> O O PRC§42956-Registration/Decal in Vehicle <br /> O O 14 CCR§18459-Responsible Entities Complying with Manifesting Requirements Date m / m / m <br /> Q O 14 CCR§18459.1 -Tire Program ID Number from CalRecycle <br /> (Required for NOV or EXE <br /> Q O 14 CCR§18459.2.1 -Submittal of Comprehensive Trip Logs within 90 days N <br /> r <br /> O O 14 CCR§18459.3-Retention of Comprehensive Trip Logs for 3 years <br /> O e ; 14 CCR§18460.2-Manifest System Requirements for Registered Waste Tire Haulers O Referred/CalRecycle Enforcement <br /> O O 14 CCR§18461 -Manifest System Requirements for Waste Tire End-Use Facilities W <br /> O O 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators •In Compliance-No Violations o <br /> Q Q Other:§ <br /> Comments hM�� Q� <br /> Inspection Form Included: Q <br /> Comments Included: <br /> Busin Signature Phone Number Inspe tor's Signature Phone Number <br /> INSTRUCTIONS ON BACK Correct:I* Incorrect: � ® q EXAMPLE 1 2 3 62081 <br /> ■ White Copy:CalRecycle Yellow Copy:Operator Pink Copy:LEA © ■ <br />