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Oa Waste Tire Survey & Inspection Report spection Report Number <br /> CalRecycle state of California 11 - 1176466 <br /> CalRecycle 181(Rev.10/10) Survey Form - Page 1 <br /> Dept of Resources Recycling and Recovery(CalRecycle) BLUE ORB LACK INK P E N <br /> Part A-Survey -- -- <br /> Business Profile Inspection Details <br /> TPID- _ ,(''� Inspection Type(Fill one) <br /> Site Suffix: ` :, J l lJ Routine Q Re-inspection Q Referral Q Observation <br /> Local \ If Referral,choose referral type(Fill one) <br /> Identifier: _J(�(�Gr✓�0 �;i r����/ Q CHP Q CalRecycle Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name l�1 Inspected By Inspector <br /> hsical Address <br /> P e-->LaLe r(�) Ave— <br /> Inspection Date / 1 <br /> TckTime In Time Out . <br /> Business Rep' TitleAM <br /> ® AM <br /> � V 0 P l ® PM <br /> n 6Xe bN 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) 3 ® Active Q Passenger ® Generator Q Outdoor <br /> Latitude O Q Closed Q Altered Q Hauler ® Indoor <br /> GPS <br /> o Q Inactive 0 Truck <br /> Longitude - Q Planned Q OTR Q End-Use Q Container <br /> Business Type(Fill all that apply) <br /> Q New Tire Dealer Q Auto Repair ® 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 ®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 14 CCR§18459-Responsible Entities Complying with Manifesting Requirements Date 1 1 N <br /> Q Q 14 CCR§18459.1 -Tire Program ID Number from CalRecycle <br /> Q Q 14 CC (Required for NOV or E)C7) N <br /> R§18459.2.1 -Submittal of Comprehensive Trip Logs within 90 days a <br /> Q Q 14 CCR§18459.3-Retention of Comprehensive Trip Logs for 3 years <br /> / <br /> Q Q 14 CCR§18460.2-Manifest System Requirements for Registered Waste Tire Haulers Q Referred CalRecycle Enforcement 2 <br /> W <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 <br /> Inspection Form Included: Q <br /> � - 7 <br /> Comments Included: Business Rep's Signa ure Phone Number Ins a or's Si n Phone Number <br /> �-�( 62081 <br /> INSTRUCTIONS ON BACK Correct:0 Incorrect: X NJ E X k E 1 2 3 ■ <br /> White Copy:CalRecycle Yellow Copy:Operator Pink Co <br /> ■ <br />