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Waste Tire Su,vey & Inspection Report Inspection Report Number <br /> State of <br /> CalRecycle CalRecyclel181(Rev.10/10) I1 - 1210364 <br /> Dept.of Resources Recycling and Recovery(CalRecycle) Survey Fora - Page 1 <br /> Part A-Survey BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- ` � CA � rn � o � � In peIon Type(Fill one) <br /> Site Suffix: � `J i'Suthe ® Re-inspection Q Referral Q Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier: sm-f �d l V� �p�,r` Q CHP Q CalRecycle Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name ` Inspected By Inspector <br /> Physical Address <br /> Z�S �1�-\ D2cv•� �1LwY <br /> C Inspection Date � / Q <br /> S2a� <br /> Time In Time Out <br /> Business Rep Title T 1 O AM 0 AM <br /> `__k S I 1 0 PM 0 PM <br /> Operational Status Tire Type Business Role Storage Type <br /> Tire Count(Whole/PTE) ,r>( (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> Z(/-� lsActive 0 Passenger 0 Generator Q Ou doq� <br /> Q Closed Q Altered // <br /> GPS Latitude Q Hauler Q Indoor <br /> o Q Inactive ® Truck <br /> Longitude - Q Planned 0 OTR Q End-Use Q Container <br /> Business Type(Fill all that apply) <br /> Q 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 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 /> PRC§42956-Registration/Decal in Vehicle <br /> Q Q 14 CCR§18459-Responsible Entities Complying with Manifesting Requirements Date 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 EXE <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 /> 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 /> n1 c cj•c S C�v�cszC <br /> c,yiceA-e\�,, qCCC�s_ Vie <br /> Inspection Form Included: Q <br /> )*0 Comments Included: Q _-!� r -- — ��- I <br /> Business ep's Signature� Phone Number Inspect 's Signature Phone Number <br /> INSTRUCTIONS ON BACK Correct:0 Incorrect: ?>< EXAMPLE 1 2 L3162081 <br /> ■ White Copy:CalRecycle Yellow Copy:Operator Pink Copy:LEA ® 0 <br />