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Waste Tire Sur vey & Inspection ReportOnspection Report Number <br /> CalRec cle State of California - 1245370 Y CalRecycle 181(Rev.10/10) Survey Forn'� ® Mage 1 1 12 4 5 3 7 0 <br /> Dept.of Resources Recycling and Recovery(CalRecycle) <br /> PBLUE OR BLACK INK PEN <br /> art A-Survey <br /> Busine s Profile Inspection Details <br /> TPID- � � � n `,� / G - � � Inspection Type(Fill one) <br /> Site Suffix: "I 1 p ` 0 Routine Q Re-inspection Q Referral Q Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier: Q CHP Q CalRecycle Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name Inspected By Inspector <br /> Physical Address <br /> Inspection Date <br /> Time In Time Out <br /> Business Rep Title ` O PM 1 I* AM <br /> O PM <br /> v c. Pew-. <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 /> ` #Active Q Passenger 0 Generator Q Outdoor <br /> D Q Closed Q Altered <br /> GPS Latitude Q Hauler Indoor <br /> 0 Q Inactive 0 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 0 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 I A I 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 /> 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 <br /> Q Q 14 CCR§18459.2.1 -Submittal of Comprehensive Trip Logs within 90 days (Required for NOV or EXT) N <br /> a <br /> Q (!D 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 o <br /> Q Q Other:§ z <br /> Comments V\ oN� <br /> Inspection Form Included: qj_ t _ <br /> Comments Included: -2b <br /> Business Rep's ignature Phone Number Inspec is Signature Phone Number <br /> 62081 <br /> INSTRUCTIONS ON BACK I Correct:* incorrect: X J) q IIEIXIAIMIPILIEI 1112 3 <br /> ■ White Copy:CalRecycle Yellow Copy:Operator Pink Copy:LEA <br />