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03 Waste Tire Sr., sjey & Inspection Repoi , Inspection Report Number <br /> Cal Rec cle State of Californ',a _ <br /> Y -CalRecycle 181(Rev.10/10) Survey Fora m Page 1- I1 1230407 <br /> Dept of Resources Recycling and Recovery(CalRecycle) <br /> Part A-Survey BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- 1 Inspection Type(Fill one) <br /> Site Suffix: 1 � 0 g 2 t & Routine Q Re-inspection Q Referral Q Observation <br /> LocalIf Referral,choose referral type(Fill one) <br /> Identifier: v;n Co JfN Q CHP Q CalRecycle Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name <br /> Inspected By Inspector <br /> Physical Address Ot <br /> Act SsS M . � <br /> Inspection Date 6 q <br /> �SZZa Time In Time out <br /> Business Rep $$ Title ® AM 0 AM <br /> �" ��A. Q PM O 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 /> 40 Active Q Passenger ` Generator • Outdoor 4 <br /> GPS Latitude 0 Closed Q Altered <br /> Q Hauler 0 indoor-3 <br /> O Q Inactive 0 Truck <br /> Longitude - Q Planned Q OTR Q End-Use ® ContainerZ <br /> Business Type(Fill all that apply) <br /> Q New Tire Dealer Q Auto Repair 4D 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 I 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 / 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 W <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 /> Commenrts�a.�1n� <br /> aC Acta ; 4- Cc Aoe _C _ -- <br /> Inspection Form Included: 0 gogl',�L <br /> Comments Included: e -`� r Z0�" 32 <br /> Business Rep's Signature Phone Number Inspe or's Signature Phone Number <br /> INSTRUCTIONS ON BACK Correct:* Incorrect: X �� ] <br /> VJE�XjAjMjPjLjEj 1112 3 62081 <br /> . White Copy:CalRecycle Yellow Copy:Operator Pink Copy:LEA ® ■ <br />