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Waste Tire Survey & Inspection Report Inspection Report Number ■ <br /> Cal6ec cle State of California — <br /> Y CalRecycle 181(Rev.10/10) Survey Form - Page 1 11 1226242 <br /> Dept.of Resources Recycling and Recovery(CalRecycle) <br /> Part A-Survey BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- h _ Inspection Type(Fill one) <br /> Site Suffix: o ! 1 ® Routine Q Re-inspection Q Referral Q Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier: S an 0 141 r� CC7V�(1�� Q CHP Q CalRecycle Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name Inspected By Inspector <br /> Physical Address C3 Lp � <br /> �R q5 Inspection Date / V 1 <br /> S�de�rzkc�� <br /> Time In Time Out <br /> Business Rep Title <br /> AM AM <br /> &W W Q 2 V` O PM ` rl <br /> v Q PM <br /> - Operational Status Tire Type Business Role Storage Type <br /> Tire Count(Whole/PTE) (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> ® Active S Passenger ® Generator ® Outdoor <br /> O Q Closed Q Altered <br /> GPS Latitude Q Hauler ® Indoor <br /> O Q Inactive * Truck <br /> Longitude - Q Planned Q 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 I- <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 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 <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 EXT) N <br /> r <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 /> W <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 O In Compliance-No Violations o <br /> Q Q Other:§ IL Ai-c"_ A AL1 a <br /> Comments D t I"\_9_ LAD ftS�c. �\SC_ astir 11 U!" T S df\ '44r C_ c4i)/� I ,\rL <br /> 0 V�O1a�iy�5 - Of U.Scc�s ( C.us�C�r11. <br /> Inspection Foam Included: Q' <br /> b <br /> Comments Included: I �J l <br /> Business ep's Signa Phone Number Inspe is Signature _ Phone Number <br /> - ?� �-,( 62081 <br /> INSTRUCTIONS ON BACK Correct: Incorrect: X �J EXAM E 2 3 <br /> ■ White Copy:CalRecycle Yellow Copy:Operator Pink Copy: © ■ <br />