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Waste Tire Sup vey & Inspection Report Inspection Report Number <br /> CalRecycle Cte of alRecyclel1fornia 181(Rev.10/10) 11 -1176715 <br /> Dept.of Resources Recycling and Recovery(CalRecycle) Su rvey Form - Page 1 <br /> Part A-Survey BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- Inspection Type(Fill one) <br /> Site Suffix: I 3 Li o ( ® Routine Q Re-inspection Q Referral Q Observation <br /> Local \,� '/( If Referral,choose referral type(Fill one) <br /> Identifier: � � /1� � '` 1� 0 CHP Q CalRecycle Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name ((( Inspected By Inspector <br /> 10 cel e�(-` )6 ckk rC <br /> Physical Address <br /> ` l <br /> "V► C\Yl� dYV� biJ <br /> 1550 ' �'lC,l& . <br /> Inspection Date ! ® Q / <br /> Time In Time Out <br /> Business Rep Title �l ® AM ® AM <br /> S'\ I_ I J 5' O PM I I Cl O PM <br /> `L�Wn � �r� `� b-A ' 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 0 Passenger ® Generator Q Outdoor <br /> D Q Closed O Altered W[/A- <br /> GPS Latitude Q Hauler Q Indoor <br /> 0 Q Inactive ® Truck <br /> Longitude - Q Planned 0 OTR O End-Use O Container <br /> Business Type(Fill all that apply) <br /> Q New Tire Dealer Q 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 ® 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 /> O O <br /> PRC§42951 -Waste Tire Hauler Registration and Transport of Tires <br /> O O PRC§42953-Contracts with Registered Waste Tire Haulers. Compliance Deadline <br /> PRC§42956-Registration/Decal in Vehicle <br /> O O 14 CCR§18459-Responsible Entities Complying with Manifesting Requirements Date m / m / m <br /> O O 14 CCR§18459.1 -Tire Program ID Number from CalRecycle <br /> O O 14 CCR§18459.2.1 -Submittal of Comprehensive Trip Logs within 90 days (Required for NOV or EXT) N <br /> O O 14 CCR§18459.3-Retention of Comprehensive Trip Logs for 3 years <br /> 0 <br /> O O 14 CCR§18460.2-Manifest System Requirements for Registered Waste Tire Haulers Q Referred/CalRecycle Enforcement <br /> O O 14 CCR§18461 -Manifest System Requirements for Waste Tire End-Use Facilities W <br /> O O 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators In Compliance-No Violations o <br /> O O Other:§ <br /> Comments <br /> Seg'-- C_,nM 'I& A_ , <br /> Inspection Form Included: . > <br /> Comments Included: �eR <br /> '�'Bp s Signature Phone Number ( s for s ig re Phone Number <br /> INSTRUCTIONS ON BACK [Oorrect-_O Incorrect: % E A M L E 1 2 3 62081 <br /> ■ White Copy:CalRecycle Yellow Copy:Operator Pink Copy:LEA © ■ <br />