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J <br /> Waste Tire Swfvey & Inspection RepoA Inspection Report Number <br /> CalRecycle CalStte of Recyclellfornia 181(Rev.10/10) <br /> Dept.of Resources Recycling and Recovery(CalRecycle) Survey Form Page I1 1226526 <br /> Part A - Survey _ BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- Inspection Type(Fill one) <br /> OSite Suffix: I -1 J J 41 Routine Q Re-inspection Q Referral Q Observation <br /> Local I If Referral,choose referral type(Fill one) <br /> Identifier: a n (�Ctl1(/I�n CU t l(� O CHP Q CalRecycle Q Complaint O Educational Visit Q Other <br /> Business or Facility Name l4 1411 Inspected By Inspector <br /> Physical Address 31 <br /> Inspection Date <br /> l• 1 Time In Time Out 111 <br /> Business Rep Title 1 AM ® AM <br /> Q PM I Q 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 /> Q Active Q <br /> Passenger Q Generator <br /> Q Outdoor <br /> d/� <br /> esLatitude O ® Closed O Altered r,v IA <br /> C <br /> O Hauler Q Indoor <br /> o Q Inactive Q Truck <br /> Longitude - Q Planned Q OTR O 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 Q Other W4 <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 /> 0 0 PRC§42951 -Waste Tire Hauler Registration and Transport of Tires <br /> Q 0 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 EX7) n <br /> O O 14 CCR§18459.3-Retention of Comprehensive Trip Logs for 3 years o <br /> O O 14 CCR§18460.2-Manifest System Requirements for Registered Waste Tire Haulers Q Referred`/CalRecycle Enforcement <br /> f <br /> O O 14 CCR§18461 -Manifest System Requirements for Waste Tire End-Use Facilities w <br /> 0 O 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators ®In Compliance-No Violations o <br /> Q O Other:§ �\ 1 1 11 <br /> Comments <br /> Al G�j 4 r Al j n �yA � Aljn15 L11l )A �1 't `( ��lt W S OaetA <br /> Uu e,1 H <br /> fie- -�,xp ()n `,4-, <br /> Inspection Form Included: Q <br /> Comments Included: Q <br /> j Business Rep's Signature Phone Number Insp or's Signature Phone Number <br /> INSTRUCTIONS ON BACK Correct:* Incorrect: X J I EXAM P L E 1 2 3 62081 <br /> 0 White Copy:CalRecycle Yellow Copy:Operator Pink Copy L LA 0 <br />