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Waste Tire Su. ✓ey & Inspection Report Inspeci:ion Report Number <br /> CalRecycle State of <br /> CalRecyclelifornia 181(Rev.10/10) y� I1 - 1210568 <br /> Dept.of Resources Recycling and Recovery(CalRecycle) Survey Form 8 — 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: ! "� �1 ® at Routine Q Re-inspection Q Referral Q Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier: �t� L%� Q CHP Q CalRecycle Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name Inspected By Inspector <br /> Physical Address <br /> Inspection Dateetij UL <br /> Time In Time Out <br /> Business Rep Title 0 AM 0 AM <br /> o PM ., S b PM <br /> Operational Status Tire Type Business Role Storage Type <br /> Tire Count(Whole/PTE) r'' (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> � � <br /> ® Active ® Passenger *Generator ® 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 Q End-Use Q Container <br /> Business Type(Fill all that apply) <br /> ® New Tire Dealer 0 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 /> 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 <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 <br /> Inspection FormIncluded: O <br /> Comments Included: ® <br /> O <br /> siness ep Sig ure Phone Number pe s S' nature Phone Number <br /> INSTRUCTIONS ON BACK Correct: Incorrect: E I X I A 1 1112 3 62081 <br /> ■ White Copy:CalRecycle Yellow Copy:Operator Pink Cop ® ■ <br />