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Waste Tire Survey & Inspection Report Inspection Report Number . <br /> Cal Recycle State of California I 1 - 1226340 <br /> CalRecycle 161(Rev.10/10) Survey Form - Page 1 <br /> Dept.of Resources Recycling and Recovery(CalRecycle) <br /> - BLUE OR BLACK INK PEN <br /> Part A Survey_ <br /> Business Profile Inspection Details <br /> TPID- � � � � � � � - /•.� � Inspection Type(Fill one) <br /> Site Suffix: �J ® Routine 0 Re-inspection 0 Referral 0 Observation <br /> Local 1 If Referral,choose referral type(Fill one) <br /> Identifier: �(� �(C)1 �1� `vwn� 0 CHP 0 CalRecycle 0 Complaint 0 Educational Visit 0 Other <br /> Business or Facility�me � Inspected By- Inspector <br /> J S -T <br /> Physical Address <br /> a - Inspection Date 3 1 <br /> co m I L Time In Time Out <br /> Title I 5 O AM C 0 AM <br /> Business Rep tt • PM J 0 PM <br /> C '(Y\elIOln Q J m <br /> Operational Status Tire Type Business Role Storage Type <br /> Tire Count(Whole/PTE) , jA <br /> O (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> ® Active 0 Passenger 0 Generator ® Outdoor <br /> O 0 Closed 0 Altered <br />• GPS Latitude 0 Hauler ® Indoor <br /> O 0 Inactive el Truck <br /> Longitude - 0 Planned 0 OTR 0 End-Use 0 Container <br /> Business Type(Fill ail that apply) <br /> 0 New Tire Dealer 0 Auto Repair 1@ Trucking Fleet 0 Government 0 Retreader 0 Dismantler 0 Tire Derived Fuel <br /> 0 Used Tire Dealer 0 Auto Body 0 Car Dealer 0 Collection 0 Crumb Rubber <br /> 0 Service Station 0 Hauler 0 Agriculture 0 Shredder 0 Other <br /> Part B - Inspection of Waste Tire Dealer, Generator, Hauler and End-Use Facility ENFORCEMENT STATUS <br /> V A HAULING AND MANIFEST REQUIREMENTS 0 Notice Of Violation 0 Extension <br /> 0 0 PRC§42951 -Waste Tire Hauler Registration and Transport of Tires <br /> 0 0 PRC§42953-Contracts with Registered Waste Tire Haulers. Compliance Deadline <br /> 0 0 PRC§42956-Registration/Decal in Vehicle <br /> 0 0 14 CCR§18459-Responsible Entities Complying with Manifesting Requirements Date m / m <br /> 0 0 14 CCR§18459.1 -Tire Program ID Number from CalRecycle <br /> 0 0 14 CCR§18459.2.1 -Submittal of Comprehensive Trip Logs within 90 days (Required for NOV or EXT) N <br /> Ln <br /> 0 0 14 CCR§18459.3-Retention of Comprehensive Trip Logs for 3 years o <br /> 0 0 14 CCR§18460.2-Manifest System Requirements for Registered Waste Tire Haulers 0 Referred/CalRecycle Enforcement <br /> 2 <br /> Lu <br /> 0 0 14 CCR§18461 -Manifest System Requirements for Waste Tire End-Use Facilities <br /> 0 0 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators <br /> in Compliance-No Violations o <br /> 0 0 Other:§ <br /> Comments y7 411 1f \ tU Ula <br /> U 1\ <br /> 16431 <br /> Inspection Form Included: 0 <br /> Comments Included: ?Busine <br /> - - <br /> ep's Signature Phone Number Insp c or's SignaturePhone Number <br /> 62081 <br /> INSTRUCTIONS ONCK Correct:IS Incorrect: <br /> ■ White Copy:CalRecycle Yellow Copy:Operator Pink Cop :LE © ■ <br />