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Waste Tireey & Inspection Repftnspection Report Number <br /> of <br /> CalRecycle CaalRecyclete 1ifornia 181(Rev.10/10) — 7 6 ■ <br /> Dept.of Resources Recycling and Recovery(CalRecycle) <br /> Survey Form Page 1 I1 1 4 9 8 <br /> Part A_ urvey- S __ BLUE OR BLACK INK PEN <br /> ---- - - -- .._..._------...-- <br /> Business Profile l Inspection Details <br /> TPID- Inspection G( 1 Inspection Type(Fill one) <br /> �"1 <br /> Site Suffix: 3 ) 5 0 + 0 Routine Q Re-inspection Q Referral Q Observation <br /> Local , � If Referral,choose referral type(Fill one) <br /> �� <br /> Identifier: �(�� JC7( ulJ1 to Q CHP Q CalRecycle Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name 1 L 1 1 Inspected By Inspector <br /> Physical Addres 3 - <br /> stO&�v ^ - Inspection Date <br /> G A Time In Time Out 1 <br /> Business Rept Title 0AM I ® AM <br /> 0 <br /> PM 0 PM <br /> Operational Status Tire Type Business Role Storage Type <br /> I <br /> Tire Count (Whole/PTE) (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> 3 <br /> ® Active Q Passenger 0 Generator ® Outdoor <br /> O Q Closed Q Altered <br /> GPS Latitude Q Hauler Q Indoor <br /> O Q Inactive • Truck <br /> Longitude - Q Planned ! OTR Q End-Use 0 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 FprW I <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 EXE n <br /> Ir <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 /> 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 <br /> U)461 nL k z rA4c,')JC.1 I [) <br /> L <br /> St©�, v <br /> no y;rJl�t;nns of 4<<c�s c7�' �u�c�cn. <br /> .2c9 <br /> Inspection Form Included: Q ^O <br /> Comments Included: <br /> Business Rep's Signa Phone Number Inspect 's Signature Phone Number <br /> 62081 <br /> INSTRUCTIONS ON BACK Correct:* Incorrect: V/ (Z.) q E X A M P L E 1 2 3 <br /> ■ White Copy:CalRecycle Yellow Copy:Operator Pink C y:L © ■ <br />