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Waste Tire Survey & Inspection Report Inspection Report Number <br /> Cal Rec cle State of California <br /> Y CalRecycle 181(Rev.10/10) <br /> Survey Form - Page 1 I1 1245154 <br /> Dept.of Resources Recycling and Recovery(CalRecycle) <br /> Part A-Surv_ey BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- Inspection Type(Fill one) <br /> Site Suffix: ` 3 i Routine Q Re-inspection Q Referral Q Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier: e2_0.jr\ G� `y V h O CHP Q CalRecycle Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name Inspected By Inspector <br /> Co v\.�l t AC_. '�tcc-v i C�Z� C.(.C. <br /> Physical Address I 13 A Al-T v <br /> Z N2w��,. tz&� �_i <br /> C %205 Inspection Date ' o � d -2 / � S <br /> Time In Time Out <br /> Business Rep ITitle 1 l PM 1 d ,� PM <br /> Operational Status Tire Type Business Role Storage Type <br /> Tire Count(V1/hole/PTE) (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> 0 Active O Passenger 0 Generator • Outdoor 7 <br /> O Q Closed Q Altered <br /> GPS Latitude Q Hauler 0 Indoor 38 <br /> O Q Inactive *Truck <br /> Longitude — Q Planned O OTR O End-Use Q Container <br /> Business Type(Fill all that apply) <br /> Q New Tire Dealer Q Auto Repair 0 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 /> 0 O PRC§42951 -Waste Tire Hauler Registration and Transport of Tires <br /> Q O PRC§42953-Contracts with Registered Waste Tire Haulers. Compliance Deadline <br /> PRC§42956-Registration/Decal in Vehicle <br /> Q O 14 CCR§18459-Responsible Entities Complying with Manifesting Requirements Date m / m / m <br /> Q O 14 CCR§18459.1 -Tire Program ID Number from CalRecycle <br /> Q O 14 CCR§18459.2.1 -Submittal of Comprehensive Trip Logs within 90 days (Required for NOV or EXE N <br /> O O 14 CCR§18459.3-Retention of Comprehensive Trip Logs for 3 years <br /> 0 <br /> O O 14 CCR§18460.2-Manifest System Requirements for Registered Waste Tire Haulers Q Referred/CalRecycle Enforcement <br /> O O 14 CCR§18461 -Manifest System Requirements for Waste Tire End-Use Facilities W <br /> O O 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators In Compliance-No Violations <br /> O O Other:§ <br /> Comments e Q��44 C" p h O'o NVQ <br /> \V <br /> �p V QCs V\� Q� Ce�S �hCQi'✓� <br /> Inspection Form Included: 0 <br /> Comments Included: • -- <br /> Business Rep's Signature Phone Number InspeSignature Phone" <br /> INSTRUCTIONS ON BACK Correct: Incorrect: E X A M P L E 1 2 3 62081 <br /> ■ White Copy:CalRecycle Yellow Copy:Operator Pink Copy:LEA © ■ <br />