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Waste Tire fervey�r� Inspection Report Number <br />& section Re o�ifornia <br />CalRecycle CalStat eof cle Cal181 (Rev.10/10) -1210441 <br />Dept. of Resources Recycling and Recovery (CalRecycle) <br />Survey Form - Page 1 I1 <br />)art A - Survey BLUE OR BLACK INK PEN <br />Business Profile Inspection Details <br />TPID - W S - v Inspection Type (Fill one) <br />Site <br />Site Suffix: <br />Local q <br />Identifier: SIX �orti 1411f% <br />1 � <br />Business or Facility Name <br />6\0k� (9 rclins C \-f C11 h Lees <br />Physical Address <br />a,vSI S_ A,rpv , <br />Will Routine Q Re -inspection Q Referral Q Observation <br />If Referral, choose referral type (Fill one) <br />Q CHP Q CalRecycle Q Complaint Q Educational Visit Q Other <br />Inspected By Inspector <br />39 - 1 0 1 Gs L()TTO <br />Inspection Date r7 / C / l <br />O c�-LC� c ySzo1� lJ <br />Time In Time Out <br />Business Rep Title O AM Q AM <br />Tire Count (Whole/PTE) <br />GPS Latitude . <br />Longitude - <br />Business Type (Fill all that apply) <br />Q New Tire Dealer Q Auto Repair <br />Q Used Tire Dealer Q Auto Body <br />Q Service Station Q Hauler <br />a 1 0* PM 01- : 6 o 40 PM <br />Operational Status Tire Type Business Role Storage Type <br />(Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br />Q Active Q Passenger Q Generator Q Outdoor <br />O ®Closed Q AI e p N <br />1 Q Ha A Q Indo bry % <br />O Q Inactive Q Truck /� <br />Q Planned Q OTR Q End -Use Q Container <br />Part B - Inspection of Waste Tire Dealer, Generator, Hauler and End -Use Facility <br />V <br />A <br />Q Trucking Fleet <br />Q Government <br />Q Retreader <br />Q Car Dealer <br />Q Collection <br />Q Crumb Rubber <br />Q Agriculture <br />Q Shredder <br />Q Other <br />Part B - Inspection of Waste Tire Dealer, Generator, Hauler and End -Use Facility <br />V <br />A <br />HAULING AND MANIFEST REQUIREMENTS <br />Q <br />Q <br />PRC § 42951 - Waste Tire Hauler Registration and Transport of Tires <br />Q <br />Q <br />PRC § 42953 - Contracts with Registered Waste Tire Haulers. <br />Q <br />Q <br />PRC § 42956 - Registration/Decal in Vehicle <br />Q <br />Q <br />14 CCR § 18459 - Responsible Entities Complying with Manifesting Requirements <br />Q <br />Q <br />14 CCR § 18459.1 - Tire Program ID Number from CalRecycle <br />Q <br />Q <br />14 CCR § 18459.2.1 - Submittal of Comprehensive Trip Logs within 90 days <br />Q <br />Q <br />14 CCR § 18459.3 - Retention of Comprehensive Trip Logs for 3 years <br />Q <br />Q <br />14 CCR § 18460.2 - Manifest System Requirements for Registered Waste Tire Haulers <br />Q <br />Q <br />14 CCR § 18461 - Manifest System Requirements for Waste Tire End -Use Facilities <br />Q <br />Q <br />14 CCR § 18462 - Manifest System Requirements for Tire Dealers or Waste Tire Generators <br />010 <br />1 Other: § <br />Comments <br />1 <br />Dismantler <br />N14 <br />Tire Derived Fuel <br />ENFORCEMENT STATUS <br />Q Notice Of Violation O Extension <br />Compliance Deadline <br />Date <br />m /m/m <br />(Required for NOV or EXT) <br />0 Referred / CalRecycle Enforcement <br />® In Compliance - No Violations <br />6j o4conerern <br />.J <br />la ter; 1A d6 —9 0 <br />Inspection Form Included: U , <br />Comments Included: Q - <br />Business Rep's Signature Phone Number Insp or's Signature <br />INSTRUCTIONS ON BACK Correct:0 Incorrect: N E X A L 1 2 3 <br />■ White Copy: CalRecycle Yellow Copy: Operator Pink Cop L <br />69-3)1 <br />Phone Number <br />62081 <br />® 0 <br />