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Waste Tire Avey & Inspection Repor.. Inspection Report Number <br /> Cal Rec cle State of California — <br /> Y CalRecycle 181(Rev.10/10) Survey Form - Page 1 I1 1245354 <br /> Dept.of Resources Recycling and Recovery(CalRecycle) <br /> Part A- Survey BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- Inspection Inspection Type(Fill one) <br /> Site Suffix: l (j l ( 0 Routine Q Re-inspection Q Referral Q Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier: In. J�clu In CCi Q CHP Q CalRecycle Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name '7 Inspected By Inspector <br /> 'Z QK�-,ress �vvc .. Cts. L t� � - 0 ( S�P()VAb I�-�O <br /> Physical dtl <br /> ��� ���� Inspection Date � / U � � r <br /> Time In Time Out <br /> Business Rep Title 0AM 0 AM <br /> © QPM I I � dPM <br /> 1��v�S cler� z_ 3 <br /> Operational Status Tire Type Business Role Storage Type <br /> Tire Count Ch)0I /PTE) (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> 0 Active Q Passenger 0 Generator Q )Outtd-oor <br /> GPS <br /> Latitude O Q Closed Q Altered Q Hauler Q Indo <br /> O Q Inactive � 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 <br /> 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 /> 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 EXE n <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 Enforcement <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 0 In Compliance-No Violations o <br /> Q Q Other:§ <br /> CommentsGlc;t-i. W,,., t) tQ iJ ` / /4 [%�Er✓(1G. <br /> GC/ <br /> ! , <br /> ON(u6W4 <br /> Inspection Form Included: Q ZOO <br /> Comments Included:0 ;4' w6j 1-4-4 -W-ZrO7 <br />- <br /> islilne_,,�)_'s Signature Phone Number Inspector's Signature Phone Number <br /> INSTRUCTIONS ON BACK Correct:* Incorrect: E X A M P L E 1112 3 62081 <br /> White Copy:CalRecycle Yellow Copy:Operator Pink Copy:LEA <br />