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Waste Tire Survey & Inspection Report Inspection Report Number . <br /> CalRec cle State of California <br /> Y calRecycle 181(Rev.10/10) Survey Form - Page 1 1 - 1196419 <br /> Dept of Resources Recycling and Recovery(calRecycle) <br /> Part A BLUE OR BLACK INK PEN <br /> -Survey <br /> Business Profile Inspection Details <br /> TPID- Inspection Type(Fill one) <br /> Site Suffix: I D 5 3 S Q O Routine Q Re-inspection Q Referral Q Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier: Q CHP Q CalRecycle Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name Inspected By Inspector <br /> 6-(' l l f <br /> Physical Address l p <br /> Inspection Date <br /> C/Aj36� Time In Time Out <br /> Business Rep Title 0 AM 0 AM <br /> L / ' J 5- 0 PM � O T ®PM <br /> 1 v\C',w� �'1 c - -- V�6t.VA_6t_Ar G <br /> `1 V_ <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 /> S d ® Active ® Passenger 0 Generator 10 Outdoor <br /> O Q Closed Q Altered <br /> GPS Latitude Q Hauler Q Indoor <br /> O Q Inactive ®Truck <br /> Longitude - Q Planned Q OTR Q End-Use ® Container <br /> Business Type(Fill all that apply) <br /> New Tire Dealer Q Auto Repair Q Trucking Fleet Q Government Q Retreader Q Dismantler Q Tire Derived Fuel <br /> ® Used Tire Dealer Q Auto Body Q Car Dealer Q Collection Q Crumb Rubber <br /> ® 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 /> ®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 /> Q Q PRC§42956-Registration/Decal in Vehicle �� <br /> Q Q 14 CCR§18459-Responsible Entities Complying with Manifesting Requirements Date F�] / ZI / [N <br /> (y f <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 EX 1) N <br /> • 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 /> M <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 Q In Compliance-No Violations <br /> Q Q Other:§ <br /> _ z <br /> Comments <br /> Inspection Form Included: Q <br /> Comments Included: ® g -Yb8-�c6 Z3 <br /> Business Rep's Signature Phone Number ec 's ignature Phone Number <br /> �-,( <br /> INSTRUCTIONS ON BACK Correct:* Incorrect: NA 4 NJ E X A P E 2 3 62081 <br /> ■ White Copy:CalRecycle Yellow Copy:Operator Pink Co :L ® ■ <br />