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Waste Tire Su,vey & Inspection Flep or-1 Inspection Report Number <br /> CalRecle State of California <br /> cycle CalRecycle 181(Rev.10110) <br /> y(Cal Survey Form - Page 1 I1 1242123 <br /> Dept.of Resources Recycling and Recovery(CalRecycle) <br /> Survey <br /> A-Survey BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- _ r Inspection Type(Fill one) <br /> Site Suffix: Li Routine Q Re-inspection Q Referral Q Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier: �l/(� ��„y� j Q CHP Q CalRecycle Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name Inspected By Inspector <br /> Physical Address ( I © <br /> Ct 3 6 E <br /> C� Inspection Date <br /> t�vrt'k Time In Time Out l <br /> Business Rep Title Z 0 AM O AM <br /> OPM 'Z' ' G .G) ® PM <br /> Operational Status Tire Type Business Role Storage Type <br /> Tire Count (Whole/PTE) 615— <br /> (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> ' ' 6 ® Active Q Passenger ® Generator ®Outdoor <br /> O 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 Q Container <br /> Business Type(Fill all that apply) <br /> Q New Tire Dealer Q Auto Repair ® 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 /> VA HAULING AND MANIFEST REQUIREMENTS <br /> Q Q - Q Notice Of Violation Q Extension <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 <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 o <br /> Q Q 14 CCR§18460.2-Manifest System Requirements for Registered Waste Tire Haulers Q Referred/CalRecycle Enforcement <br /> 2 <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 <br /> ia In Compliance-No Violations o <br /> Q Q Other:§ - <br /> Comments <br /> Inspection Form Included: O <br /> Comments Included: ® © <br /> usiness Rep' ig Phone Number a r' ture Phone Number <br /> 62081 <br /> INSTRUCTIONS ON BACK Correct:0 Incorrect: E X A 1112 3 <br /> ■ White Copy:CalRecycle Yellow Copy:Operator Pink Copy: ® ■ <br />