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Waste Tire Su. vey & Inspection Re or0Inspection Report Number <br /> p p <br /> CalRec cle State of California — <br /> Y calRecycle181(Rev.10/10) Survey Form - Page 1 I1 1242502 <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_ O I Inspection Type(Fill one) <br /> Site Suffix: ` * Routine Q Re-inspection Q Referral Q Observation <br /> Localf If Referral,choose referral type(Fill one) <br /> Identifier: S A n J o a g i t t n U-LA n ' v1 Q CHP Q CalRecycle Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name Inspected By Inspector <br /> C011k0Ing ��►��- �1�fu,5� �-n�- 3 _ v _ <br /> Physical Address <br /> '310S_ S _ EC( Qyrar�o <br /> Inspection Date <br /> or,n CA `iS�-o(o J <br /> Time In Time Out <br /> Business Rep Title y 0 AM 0 AM <br /> F <br /> O�Ci`!L Iu1 �trl(l�flq� S 4P PM 3 0 PM <br /> u cf- Operational Status Tire Type Business Role Storage Type <br /> Tire Count(Whole/PTE) S G (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> 1 0 Active Q Passenger ® Generator Q Outdoor <br /> Q Closed Q Altered <br /> GPS Latitude Q Hauler ® Indoor <br /> 0 Q Inactive If 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 • 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 Notice Of Violation Q Extension <br /> Q Q 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 / m <br /> Q Q 14 CCR§18459.1 -Tire Program ID Number from CalRecycleLn <br /> Q Q 14 CCR§18459.2.1 -Submittal of Comprehensive Trip Logs within 90 days (Required for NOV or EX N <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 /> 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 e In Compliance-No Violations o <br /> Q Q Other:§ <br /> Comments QOIA h. VA 6A4, �)'js—1 i� /b2p TM1fL, �l �r ►1�T �/�1 Q� �7 1� <br /> \1 O ' l l <br /> ()I (,I S e to S p+ C VJ)Ccr n <br /> Inspection Form Included: QCZ6 '" �a -31"78 <br /> Comments Included: ® yG 7 U! <br /> B iness Rep's signaturl Phone Number Instoy's Signature Phone Number <br /> INSTRUCTIONS ON BACK ICorrect: Incorrect: EJJ �XAM 1 2 3 62081 <br /> White Copy:CalRecycle Yellow Copy:Operator Pink Copy:L A <br />