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------------------- <br /> ■ Oa Waste TDre Survey & Ir1spsclGan Report Inspection Report Number ■ <br /> Cal Rec cle State of California — <br /> Y CalRecycle 181(Rev.10/10) �urVey ®rm - gage i� I1 1242222 <br /> Dept.of Resources Recycling and Recovery(CalRecycle) <br /> Part A-Survey <br /> BLUE OR BLACK_INK PEN <br /> Business Profile Inspection Details <br /> TPID- , _ Inspection Type(Fill one) <br /> Site Suffix: , IV Routine Q Re-inspection Q Referral Q Observation <br /> Local Cv If Referral,choose referral type(Fill one) <br /> Identifier: �.1�1 � b� ' Q CHP Q CalRecycle Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name Inspected By Inspector <br /> Physical Address NCA <br /> Inspection Date <br /> Arm fv �T�p� pt / s <br /> Time In Time Out <br /> Business Rep Title 0 AM I _ i 0 AM <br /> I Z -5 ® PM t 6 (wpm <br /> Operational Status Tire Type Business Role Storage Type <br /> Tire Count (Whole/PTE) j (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> ' ' t 10 Active 40 Passenger ® Generator Q Outdoor <br /> O Q Closed Q Altered <br /> GPS Latitude Q Hauler �'Indoor <br /> O Q Inactive ® Truck <br /> Longitude - Q Planned ® 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 (a Other �r <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 <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) <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 /> 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 In Compliance-No Violations o <br /> Q Q 1 Other:§ <br /> Comments <br /> Inspection Form Included: <br /> Comments Included: <br /> Bu ne s Rep's Signature Phone Number In a or's ig ture Phone Number <br /> 62081 <br /> INSTRUCTIONS ON A Correct:0 Incorrect: E X A P LIE I 1112131 <br /> ■ White Copy:CalRecycle Yellow Copy:Operator Pin C p ® ■ <br />