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Waste Tire Survey & Inspection Report Inspection Report Nurnber <br /> Cal6ecyCle State of California 11 - 1226608 <br /> CalRecycle 181(Rev.10/10) Survey Form - Page 1 <br /> Dept.of Resources Recycling and Recovery(CalRecycle) <br /> BLUE OR BLACK INK PEN <br /> Part A-Survey <br /> Business Profile Inspection Details <br /> TPID- Inspection Type(Fill one) <br /> Site Suffix: 1 3 y 1 v� ® Routine Q Re-inspection Q Referral Q Observation <br /> Local _�1 If Referral,choose referral type(Fill one) <br /> Identifier: �✓v � �`��- 60VVt4 j Q CHP Q CalRecycle 0 Complaint Q Educational Visit Q Other <br /> Business or Facility Name Inspected By Inspector <br /> A <br /> Ph sical AddressA, <br /> Inspection Date <br /> Time In Time Out <br /> Business Rep Title 0 AM AM <br /> • 3 0 0 PM U b G 0 PM <br /> Operational Status Tire Type Business Role Storage Type <br /> (Fill one only) (Fill all that apply) (Fill all that apply) (Fill ail that apply) <br /> Tire Count (Whole/PTE) D <br /> ® Active ® Passenger ® Generator ® Outdoor <br /> Q Closed Q Altered <br /> GPS Latitude Q Hauler Q Indoor <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 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 m N <br /> Q Q 14 CCR§18459.1 -Tire Program ID Number from CalRecycle <br /> Q Q 14 CCR§18 - — (Required for NOV or EXn N <br /> 459.2.1 Submittal of Comprehensive Trip Logs within 90 days <br /> Q :P( 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 /> ui <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 /> Comments Included: <br /> Bus s Si nature Phone Number Ins p tor's na re Phone Number <br /> 62081 <br /> INSTRUCTIONS ON BACK Correct: Incorrect: VX ,W V X A M P E 1 2 3 <br /> ■ White Copy:CalRecycle Yellow Copy:Operator Pink Cop : ® ■ <br />