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M Waste Tire Survey & Inspection Report Inspection Report Number <br /> CalRecycle State of California 11 - 1226512 <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- 11 Inspection Type(Fill one) <br /> Site Suffix: 5 C� l C.' ® Routine Q Re-inspection Q Referral Q Observation <br /> Local � If Referral,choose referral type(Fill one) <br /> Identifier: `Cs�� `J�vt� �'�� Q CHP Q CalRecycle Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name Inspected By Inspector <br /> Physical Tdress <br /> Inspection Date q z l <br /> 1 <br /> Time In l Time Out <br /> Title ®AM O AM <br /> Business Rep 6 1} , � l O PM l Z 3 �j PM <br /> y1 1 Y�Y`L� CI�Z hVYI __ f LGt C Operational Status Tire Type Business Role Storage Type <br /> (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> Tire Count(Whole/PTE) ® Active Q Passenger ® Generator ® Outdoor <br /> Q Closed Q Altered Q Hauler ® Indoor <br /> GPS Latitude <br /> O Q Inactive ® Truck <br /> Longitude - Q Planned Q OTR Q End-Use ® Container <br /> Business Type(Fill all that apply) <br /> Q New Tire Dealer Q Auto Repair 0 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 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 m a <br /> Q Q 14 CCR§18459.1 -Tire Program ID Number from CalRecycle <br /> Q Q 14 CCR§1845 - (Required for NOV or EXE � <br /> 9.2.1 Submittal of Comprehensive Trip Logs within 90 days <br /> Q Q 14 CCR§18459.3-Retention of Comprehensive Trip Logs for 3 years c <br /> Q Q Referred/CalRecycle Enforcement <br /> 14 CCR§18460.2-Manifest System Requirements for Registered Waste Tire Haulers Q y Lu <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:§ <br /> Comments <br /> Inspection Form Included: Q <br /> -�/ `67 <br /> Comments Included: I p Phone Nu <br /> mber <br /> ;Bu eps Signatu Phone � i 62081 <br /> EXAMPLEINSTRUCTIONS ON BACK �Correct:0 Incorrect: <br /> 2 2 3 <br /> ■ White Copy:CalRecycle Yellow Copy:Operator Pink Copy:LEA ® ■ <br />