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Waste Tire Sui vey & Inspection Report0lnspection Report Number <br /> StatCalirn'CalRecycle CalRecycle 181(Rev.10/10) ■ <br /> I1 1242444 <br /> Dept.of Resources Recycling and Recovery(CalRecycle) Survey Form - Page 1 <br /> Part A-Survey____--- BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- 1 09 I C - Inspection Type(Fill one) <br /> Site Suffix: ` 0 Routine Q Re-inspection Q Referral Q Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier: SCIh ��Q Q CHP Q CalRecycle Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name -1 Inspected By Inspector <br /> MaA-ec0. q - <br /> O 1 AAT`�C V <br /> Physical Address <br /> 20k W, 1�c�,7w\ <br /> Inspection Date <br /> Time In GG Time Out <br /> Business Rep Title 2 0 AM 0 O AM <br /> 4 PM 4b PM <br /> (✓��,5 �� �� � � �` Operational Status Tire Type Business Role Storage Type <br /> Tire Count(Whole q (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> 1 d <br /> Active 0 Passenger ® Generator 16 Outdoor <br /> Latitude Q Closed Q Altered <br /> GPS Q Hauler Indoor <br /> Q Inactive Q Truck <br /> Longitude - Q Planned Q OTR Q End-Use 0 Container <br /> Business Type(Fill all that apply) <br /> 1111 New Tire Dealer Q Auto Repair Q Trucking Fleet Q Government Q Retreader Q Dismantler Q Tire Derived Fuel <br /> 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 <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 /> PRC§42956-Registration/Decal in Vehicle <br /> Q Q 14 CCR§18459-Responsible Entities Complying with Manifesting Requirements Date 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 .In Compliance-No Violations <br /> Q Q Other:§ \ ^ <br /> CommentsecN ice!\ �j2 &S c� h� <br /> 9-- IN k J�&S-,—\el"'� <br /> C <br /> Inspection Form Included: <br /> Comments Included. <br /> ' �� <br /> Busin ss Rep's Signature Phone Number Inspec or's Signature Phone Number <br /> INSTRUCTIONS ON BACK Correct: Incorrect: X E X A M P L E 1 2 3 62081 <br /> jj � jjjj■ White Copy:CalRecycle Yellow Copy:Operator Pink Copy:LEA ® ■ <br />