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Oa Waste Tirelke & Inspection Repo, - Inspection Report Num'ber <br /> E <br /> CalRecycle State of California Y p _ r I — I ( �� <br /> CalRecycle181(Rev.10/10) Survey Form Page 1 11 6 6 <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� �y � I_ _ Q � Inspection Type(Fill one) <br /> Site Suffix: 3 l �q 0 Routine Q Re-inspection Q Referral Q Observation <br /> Local 7 If Referral,choose referral type(Fill one) <br /> Identifier: (� J1)C4, L6 n CE71�i�n1�1 Q CHP Q CalRecycle Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name 1 J Inspected By Inspector <br /> Physical Addres I�Cn E�Z0 <br /> Inspection Date <br /> Time In Time Out <br /> Business Rep Title ! � O 0 AM 0 AM <br /> Aks <br /> G r Q PM PM <br /> 1 1 <br /> Operational Status Tire Type Business Role Storage Type <br /> Tire Count (Whole/PTE) C a (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> ' J ® Active ® Passenger ® Generator 0 Outdoor <br /> o Q Closed Q Altered <br /> GPS Latitude Q Hauler Q Indoor <br /> O Q Inactive Q Truck <br /> Longitude - Q End-Use Container <br /> Q Planned Q OTR <br /> Business Type(Fill all that apply) <br /> New Tire Dealer 48 Auto Repair Q Trucking Fleet Q Government Q Retreader Q Dismantler Q Tire Derived Fuel <br /> J 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 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 /> Q Q 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 /> a <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 /> Uj <br /> W <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 Other:§ z <br /> Comments I <br /> - <br /> 3c,_a, <br /> Inspection Form Included: Q 9 <br /> Comments Included: Mlumb,"r� <br /> Business Rep's Signature Phone Number Inspect5Signature/ P <br /> INSTRUCTIONS ON BACK Correct:* Incorrect: ) E X A M 1 2 3 62081 <br /> White Copy:CalRecycle Yellow Copy:Operator Pink Cop ® 0 <br />