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Waste Tire Su. Bey & Inspection Report Inspection Report Number <br /> CalRecle State of California <br /> cycle Y CalRecycle 181(Rev.10/10) Survey Form - Page 1 I1 - 1229957 <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 Type(Fill one) <br /> Site Suffix: 1 L LA - C) 1 0 Routine Q Re-inspection Q Referral Q Observation <br /> Local / If Referral,choose referral type(Fill one) <br /> Identifier: So V CV-\ CoV,� Q CHP Q CalRecycle Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name Inspected By Inspector <br /> � �vk �� 5 c� - 1 <br /> Physical Address O 1 <br /> Inspection Date <br /> Time In Time Out <br /> Business Rep Title I *AM ` S AM <br /> A ( Q PM , ` O PM <br /> 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 /> 0 Active 0 Passenger 0 Generator 0 Outdoor <br /> Q Closed Q Altered <br /> GPS Latitude Q Hauler Q Indoor <br /> 0 Q Inactive Q 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 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 <br /> Q Service Station Q Hauler Q Agriculture Q Shredder i Other n' rvCt GeSS�(`iQ S <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 <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 •In Compliance-No Violations o <br /> Q Q Other:§ c <br /> Comments <br /> Inspection Form Incict ed: Q 4 <br /> Comments Included: * -3 7 ` / I 2Q 1�_�D D"-,32 <br /> ep's Signature Phone Number Inspect 's Signature Phone Number <br /> INSTRUCTIO BACK Correct:40 Incorrect: � � g �� EJXJAJM P L E 111273 62081 <br /> White Copy:CalRecycle Yellow Copy:Operator Pink Copy:LEA <br />