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Waste Tire S`vey & Inspection Repo Inspection Report Number ■ <br /> CalRecycle State of California 11 - 1176352 <br /> CalRecycle 181(Rev.10/10)' Survey Form - Page 1 <br /> Dept.of Resources Recycling and Recovery(CalRecycle) <br /> Part A_ - Survey BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- In <br /> spection� 1 '� <br /> Inspection Type(Fill one) <br /> Site Suffix: l ® Routine Q Re-inspection Q Referral Q Observation <br /> Local e— I 1_ If Referral,choose referral type(Fill one) <br /> Identifier: � D J Oct,(,`I^ Cdt�n Q CHP Q CalRecycle Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name <br /> n ^1 I 1111 Inspected By Inspector <br /> Physical Address <br /> Street Inspection Date <br /> City State ZIP Code Time In Time Out <br /> Business Rep Title I O AM Q AM <br /> t I O PM /s PM <br /> Operational Status Tire Type Business Role Storage Type <br /> I j <br /> Tire Count(Whole/PTE) (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> i <br /> L—L � 'I___j_ _ I_ � ® Active Q Passenger ® Generator is Outdoor <br /> Q Closed Q Altered <br /> GPS Latitude Q Hauler `�®�Indoor <br /> (� 0 Q Inactive a Truck <br /> Longitude - I . Q Planned Q OTR Q End-Use Q Container <br /> Business Type(Fill all that apply) <br /> Q New Tire Dealer 0 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 <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 Q PRC§42951 -Waste Tire Hauler Registration and Transport of Tires Q Notice Of Violation Q Extension <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 * 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 EXn 61 <br /> r; <br /> Q Q 14 CCR§18459.3-Retention of Comprehensive Trip Logs for 3 years <br /> Q Q 14 CCR§18460.2.-Manifest System Requirements for Registered Waste Tire Haulers Q Referred/CalRecycle Enforcement <br /> f <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 <br /> In Compliance-No Violations o <br /> Q Q Other:§ <br /> f z <br /> Comments 1(Vi, �(,�S 1 J�- � nS � � OI _ MI�—[�_(,(,� N <br /> Inspection Form Included: Q N <br /> Comments Included: ® - — 1 &tr, <br /> �`�1-1�AM-J9 <br /> iness Rep ignatur Phone umber Inspeignature oumber <br /> 62081 <br /> INSTRUCTIONS ON BACK [Porrect:0 .Incorrect: E X A M P L .E 1 2 3 <br /> ■ White Copy:CalRecycle Yellow Copy:Operator Pink Copy:LEA ® ■ <br />