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Waste Tire Su. ,iey & Inspection Report rispection Report Number <br /> cle State of California <br /> CalRecycle — <br /> Y calRecycle181(Rev.10/10) Survey Form m Pale 1 I1 1178016 <br /> Dept.of Resources Recycling and Recovery(CalRecycle) <br /> Part A- Surve BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- � � 0 � � _ O 7 Inspection Type(Fill one) <br /> Site Suffix: Q l &Routine Q Re-inspection Q Referral Q Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier: Soon�Q 11,�,i Q CHP Q CalRecycle Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name Inspected By Inspector <br /> A ( njPhysical Address 3 f <br /> D In Ce- 10 <br /> ^^ � Inspection Date <br /> �A Time In Vl Time Out <br /> Business Rep TitleTT O AM S 0 AM <br /> V Cfn 2 ' I M in ' 3 V 0 PM J &PM <br /> _- C 'J n(��, ' ` , Operational Status Tire Type Business Role Storage Type <br /> Tire Count (Whole/PTE) 5- V7 (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> ! Active Q Passenger ® Generator • Outdoor <br /> Q Closed Q Altered <br /> GPS Latitude Q Hauler Q Indoor <br /> O Q Inactive ® Truck <br /> Longitude — Q Planned Q OTR Q End-Use ® Container <br /> Business Type(Fill all that apply) <br /> Q New Tire Dealer Q Auto Repair I* 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 /> PRC§42956-Registration/Decal in Vehicle <br /> Q Q 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) N <br /> Q Q 14 CCR§18459.3-Retention of Comprehensive Trip Logs for 3 years Lo <br /> Q Q 14 CCR§18460.2-Manifest System Requirements for Registered Waste Tire Haulers Q Referred/CalRecycle Enforcement <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 Q Other:§ <br /> Comments AIM S ) j S <br /> 1 <br /> V 1'0 114 -- <br /> Inspection Form Included: O ^ <br /> '-ii1 2 9 <br /> Comments Included: O 4 - <br /> 4siness Rep's Signature` Phone Number Inspe r s Signature Phone Number <br /> INSTRUCTIONS ON BACK Correct:* incorrect: �V;yNJ E X,A M P L E 1 2 3 62081 <br /> ® White Copy:CalRecycle Yellow Copy:Operator Pink CVEA ® ■ <br />