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Waste Tire Survey & Inspection Report. Inspection Report Number <br /> CalRecycle State of California — I 1 - l176365 l 17 6 3 6 5 <br /> CalRecycle 181(Rev.10/10) Survey Form Page 1 1. V <br /> Dept of Resources Recycling and Recovery(CalRecycle) <br /> Part A-Survey____--- __ ___ __ BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- l Inspection Type(Fill one) <br /> Site Suffix: ` 3 n 6 -7 -7 Q t e Routine Q Re-inspection Q Referral Q Observation <br /> Local / _i� If Referral,choose referral type(Fill one) <br /> Identifier: scj., "J UA! bo'y l eL Q CHP Q CalRecycle Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name V Inspected By Inspector <br /> Physical Address l 0 �� YVI <br /> � ,//-�► Inspection Date <br /> L� Time In Time Out l <br /> Business Rep Title5— 0 AM <br /> ® PM O 5— ® PM <br /> leafG`��� Operational Status Tire Type Business Role Storage Type <br /> Tire Count (Whole/PTE) t ` (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> '( (10 Active Q Passenger ® Generator ® Outdoor <br /> O Q Closed Q Altered <br /> G FS Latitude Q Hauler Q Indoor <br /> O Q Inactive ®Truck <br /> Longitude — Q Planned Q OTR Q End-Use a Container <br /> Business Type(Fill all that apply) <br /> ® 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 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 /> Q Q PRC§42956-Registration/Decal in Vehicle <br /> Q Q 14 CCR§18459-Responsible Entities Complying with Manifesting Requirements Date m <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 Exn N <br /> r <br /> N <br /> Q Q 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 /> Lu <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 V'©D <br /> 'Y6 <br /> Comments Included: <br /> ® <br /> Busi s Signature Pho umber I e o s ure Phone Number <br /> INSTRUCTIONS ON BACK Correct:* Incorrect: 62081� � � EXAM L 1 2 3 <br /> ■ White Copy:CalRecycle Yellow Copy:Operator Pink Co :L © ■ <br />