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02 Waste Tire Survey & Inspection Repon Inspection Report Number <br /> CalRecycle State of California I 1 - 1226228 <br /> CalRecycle 181(Rev.10/10) Survey Form - Page 1 <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- I, q [ < /� Inspection Type(Fill one) <br /> Site Suffix: �( V I $ J J V I • Routine Q Re-inspection Q Referral Q Observation <br /> LocalC /� u If Referral,choose referral type(Fill one) <br /> Identifier: Jin �C�fi��j\,k\r\ l�k \I Q CHP Q CalRecycle Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name4J Inspected By Inspector <br /> T <br /> Physical Address <br /> Inspection Date <br /> 110 GrT �5a� Time In Time Out <br /> Business Rep Title O AM ) ) e 0 AM <br /> II a 1 O PM 0 PM <br /> Operational Status Tire Type Business Role Storage Type <br /> (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> Tire Count(Whole/PTE) �9 <br /> ® Active � Passenger ® Generator A Outdoor <br /> O Q Closed Q Altered <br /> GPS Latitude Q Hauler Q Indoor <br /> O Q Inactive Q Truck <br /> Longitude - Q Planned Q OTR Q End-Use Q Container <br /> Business Type(Fill all that apply) <br /> Q New Tire Dealer ® 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 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 N <br /> Q Q 14 CCR§18459.2.1 -Submittal of Comprehensive Trip Logs within 90 days (Required for NOV or EXn N <br /> u) <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 /> 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:§ z <br /> Comments C9 1�cr �(�S�L �l` fQ l\5 pr1° (71l iS ( -an� a- <br /> Inspection Form�nc <br /> ncluded: Q <br /> Comments luded: ®-- <br /> usiness Rep's Signature Phone Number Insp tor' ignature Phone Number <br /> �-/ 62081 <br /> INSTRUCTIONS ON BACK Correct:* Incorrect: X � VJ E X A P L <br /> WhiteCalRecycle <br /> 1 2 3 <br /> ■ Copy:CalRec <br /> © • <br /> ycle Yellow Copy:Operator Pink Co A <br />