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Waste Tire St.. vey & Inspection Repori, Inspection Report NumberState of <br /> ■ <br /> CalRecycle CalRecycle1Caifornia <br /> 181(Rev.10110) 11 - 1226256 <br /> Dept of Resources Recycling and Recovery(CalRecycle) Su rvey Form — Page 1 <br /> Part A-Survey BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- Inspection Type(Fill one) <br /> Site Suffix: LI O Q � 0 Routine Q Re-inspection Q Referral Q Observation <br /> Local �� �� CSL 1_ If Referral,choose referral type(Fill one) <br /> Identifier: J L Q CHP Q CalRecycle Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name Inspected By Inspector <br /> �c1 V10IzNS�c� _ <br /> Physical Address <br /> Inspection Date <br /> Time In Time Out <br /> Business Rep Title O AM -7 CJO AM <br /> < PM PM' /le � <br /> /1ZG,I 4. eC <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 /> QP Active Q Passenger ® Generator ® Outdoor <br /> o Q Closed Q Altered <br /> GPS Latitude Q Hauler Q Indoor <br /> O Q Inactive Q Truck <br /> Longitude - Q Planned 0 OTR Q End-Use Q Container <br /> Business Type(Fill all that apply) <br /> Q New Tire Dealer Q Auto Repair Q Trucking Fleet Q Government Q Retreader Q Dismantler Q Tire Derived Fuel <br /> Q Used Tire Dealer Q Auto Body Q Car Dealer Q Collection Q Crumb Rubber <br /> Q Service Station Q Hauler Q Agriculture Q Shredder ® 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 Q PRC§42951 -Waste Tire Hauler Registration and Transport of Tires Q Notice Of Violation Q Extension <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 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) N <br /> _ a <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 Enforcernent <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 <br /> see, Lowmnjlz <br /> Inspection FormIncluded: 01 Vp <br /> Comments Included: ® 14 A <br /> -- <br /> Business a gn ure Phone Number s ct6r' S' ture Phone Number <br /> INSTRUCTIONS ON BACK Correct:0 Incorrect: E X A M P L El 1112 3 62081 <br /> 0 White Copy:CalRecycle Yellow Copy:Operator Pink Co :L L;4 ■ <br />