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Waste Tire SL.. vey & Inspection Report Inspection Report Number <br /> Cal Rec I 1 1196292 <br /> cle State of California m <br /> Y 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- Inspection Type(Fill one) <br /> Site Suffix: r ?j �j t Routine Q Re-inspection Q Referral Q Observation <br /> Local \ J If Referral,choose referral type(Fill one) <br /> Identifier: 11 `ICY i�l� �t�1/�rz-1 Q CHP Q CalRecycle Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name / Inspected By Inspector <br /> Physical Address t 1 In Q L <br /> Inspection Date <br /> ES cc,,, GSL 'i. <br /> f ! E 1 <br /> Time In Time Out <br /> Business Rep Title O AM O AM <br /> ( � 5 � ®PM p2 5L © ® PM <br /> LG .�c�tit►'IJ '���i,titiL <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 /> QP Active ® Passenger I&Generator ® Outdoor <br /> O Q Closed Q Altered <br /> GPS Latitude Q Hauler ® Indoor <br /> O 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 Q Trucking Fleet 40 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 - O Notice Of Violation Q Extension <br /> Q Q PRC§42953-Contracts with Registered Waste Tire Haulers. Compliance Deadline <br /> PRC§42956-Registration/Decal in Vehicle <br /> QQ 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 CalRecycle a <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 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 /> 2 <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 1 Q Other: <br /> Comments <br /> Inspection Form Included: <br /> Comments Included: 6ZJ 2 <br /> Busin s Rep' Ignature hone Number ect is at a Phone Number <br /> INSTRUCTIONS ON BACK Correct:I• Incorrect: E X M L 1 2 3 62081 <br /> ■ White Copy:CalRecycle Yellow Copy:Operator Pink Copi: ® ■ <br />