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Waste Tire Survey & Inspection Report Inspection Report Number <br /> Cal Rec cle State of California - 1226338 Y CalRecycle 181(Rev.10/10) Survey Form - Page 1 1 12 2 6 3 3 8 <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: 13 "' -1 v I IID Routine Q Re-inspection Q Referral Q Observation <br /> Local �- 1 Co a If Referral,choose referral type(Fill one) <br /> Identifier: a (� J 6&1.I�A n � 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 1 C�f,s�,�� Title 0 AM 1�1( 0 AM <br /> !`1_n ar K. fY1knG�ef�1�'�u�N� � • 0 U 0 PM 1 O t7 's PM <br /> 05 �Ur r�e� a Y"(N - <br /> Operational Status Tire Type Business Role Storage Type <br /> O (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> Tire Count(Whole/PTE) <br /> ® Active 0 Passenger ® Generator Outdoor <br /> Q Closed ® Altered <br /> GPS Latitude Q Hauler Indoor <br /> D Q Inactive 0 Truck <br /> Longitude - Q Planned Q OTR End-Use ® 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 /> 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 <br /> 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 0 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 <br /> Q Q 14 CCR§18459.2.1 -Submittal of Comprehensive Trip Logs within 90 days (Required for NOV or EX7) <br /> Q Q 14 CCR§18459.3-Retention of Comprehensive Trip Logs for 3 years o <br /> Q O 14 CCR§18460.2-Manifest System Requirements for Registered Waste Tire Haulers Q Referred/CalRecycle Enforcement <br /> 2 <br /> LU <br /> Q Q 14 CCR§18461 -Manifest System Requirements for Waste Tire End-Use Facilities <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:§ <br /> Comments ) <br /> s re <br /> LVy�1-1-�I —4�1�S -L�A �C �C V� �i��14�f• -a <br /> Inspection Form Included: ® PIZJ <br /> Comments Included: ®- - <br /> Business Reps Slgndture Phone Number Inspeis Signature Phone Number <br /> 62081 <br /> INSTRUCTIONS ON BACK Correct:is Incorrect: EXA L 1 2 3 <br /> ■ White Copy:CalRecycle Yellow Copy:Operator Pink py- A © ■ <br />