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Waste Tire Survey & Inspection Report Inspection Report Number <br /> CalRecycle State of California — <br /> Y CalRecycle 181lRev.10/10) Survey Form - Page 1 1 1230434 <br /> Dept.of Resources Recycling and Recovery(CalRecycle) <br /> BLUE OR BLACK INK PEN <br /> Part A- Survey <br /> Business Profile Inspection Details <br /> TPID- Inspection Type(Fill one) <br /> Site Suffix: J CI 0 Routine Q Re-inspection Q Referral Q Observation <br /> (, C <br /> Local 1 If Referral,choose referral type(Fill one) <br /> Identifier: x' �� ��� � '` Q CHP Q CalRecycle Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name Inspected By Inspector <br /> Physical Address 'J ( �Kj �LIL4 <br /> rpt� � - Gi�►U.,/�--� e-�c� - <br /> Inspection Date <br /> Time In Time Out <br /> Business Rep Title 0 AM 2 0 AM <br /> • ® PM V �4j 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 /> oZ ®Active Q Passenger ® Generator Q Outdoor <br /> O Q Closed Q Altered <br /> �PS Latitude Q Hauler ®•Indoor <br /> 0 Q Inactive ® 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 <br /> PRC§42951 -Waste Tire Hauler Registration and Transport of Tires <br /> Q V 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 <br /> Q Q 14 CCR§18459.1 -Tire Program ID Number from CalRecycle N <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 0 14 CCR§18460.2-Manifest System Requirements for Registered Waste Tire Haulers Q Referred/CalRecycle Enforcement <br /> 2 <br /> W <br /> Q Q 14 CCR§18461 -Manifest System Requirements for Waste Tire End-Use Facilities <br /> Q O 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators ®In Compliance- No Violations o <br /> Q Q Other:§ <br /> Comments <br /> Inspection Form Included: Q y <br /> Comments Included: 0Busin p s Signature �" <br /> 3-0 <br /> Phone Number Ins aor's ure y <br /> Number <br /> 62081 <br /> i INSTRUCTIONS ON BACK Correct: Incorrect: X E X 1 Z 3 <br /> White Copy:CalRecycle Yellow Copy:Operator Pink p <br />