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Waste Tire Su. wey & Inspection Report inspection Report Number <br /> Ycle State of CaliforniaC81Rec <br /> CalRecycle 181(Rev.10/10) Survey Form - Page 1 I1 1230119 <br /> Dept.of Resources Recycling and Recovery(CalRecycle) <br /> Part A-Survey BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- � � O � Inspection Type(Fill one) <br /> Site Suffix: i Routine Q Re-inspection Q Referral Q Observation <br /> Local / If Referral,choose referral type(Fill one) <br /> Identifier: J0!1 4 j r1 l(j Uln Q CHP Q CalRecycle Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name ` Inspected By Inspector <br /> Physical Addre�sul rl �dun�V) t ilt i I �U(/Lrl d�S <br /> , Inspection Date / Q ' S <br /> 0&Z't o-rN CA �S?,olO <br /> Time In Time Out <br /> Business Rep Title G AM 1 O AM <br /> 11 C�1 CE O S O 40 PM o' U ® PM <br /> S - — 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 /> ® Active 40 Passenger 0 Generator Q Outdoor <br /> Latitude O Q Closed Q Altered NIA <br /> GPS Q Hauler Q Indoor <br /> O Q Inactive ®Truck <br /> Longitude - Q Planned ® 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 r <br /> Q Service Station Q Hauler Q Agriculture Q Shredder + Other Cb1A4 <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 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 o <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 <br /> in Compliance-No Violations o <br /> Q Q1 Other:§ <br /> Comments "inpair, t A zkt 1fj <br /> VQ <br /> .0 AC-6 '% i ,J <br /> Inspection Form Included: Q A <br /> Comments Included:® &L-31711 <br /> Business R 's Signature Phone Number Ins tor's Signature Phone Number <br /> INSTRUCTIONS ON BACK Correct: Incorrect: KA E I X I A IM L JEJ 111213] 62.081 <br /> 0 White Copy:CaIR�K Yellow Copy:Operator Pink Co y:L <br />