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0 Waste Tire Su. ey & Inspection Report nspection Report Number ■ <br /> CalRecycle state of California _ <br /> CalRecycle 181(Rev.10/10) I1 1196474 <br /> Dept.of Resources Recycling and Recovery(CalRecycle) Survey Form - Page 1 <br /> Part A-Survey BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- � � � '5 O � t� - © , Inspection Type(Fill one) <br /> Site Suffix: &Routine Q Re-inspection Q Referral Q Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier: 12CLh k3j% Q CHP Q CalRecycle Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name <br /> / Inspected By Inspector <br /> � <br /> nl�,��..o, Q�����019�e� ,,�e. u�.h v�� 3 _ d o l <br /> P ysica A dress 9 M A -rTv <br /> 2866 `F�cv\I� Ca,M � `r��.,2, <br /> � Inspection Date <br /> `"C'v� ��2 6� Time In 1 Time Out 111 <br /> Business Rep Title n 2 *AM 9 * AM <br /> "1 QPM QPM <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 /> Q Active Q Pa en er Q Genn`errator Q Outdoor <br /> Latitude O 0 Closed Q Alte X , ` N`A <br /> G�S Q Hauler Q Indoor <br /> O Q Inactive Q Truck <br /> Longitude - Q Planned Q 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 • 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 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 / m / m <br /> Q Q 14 CCR§18459.1 -Tire Program ID Number from CalRecycle I <br /> Q Q 14 CCR§18459.2.1 -Submittal of Comprehensive Trip Logs within 90 days (Required for NOV or EXT) n <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 Q 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators IS In Compliance-No Violations o <br /> Q Q Other:§ <br /> Comment, <br /> �A_4�'2 � \ <br /> \�4�'nE v�.cz� • <br /> Inspection Form Included: Q _ ���`^'� <br /> Comments Included: <br /> Business Rep's Signature Phone Number Inspector' Sig ature Phone Number <br /> INSTRUCTIONS ON BACK I Correct:0 Incorrect: EXAMPLE Z 2 3 62081 <br /> ■ White Copy:CalRecycle Yellow Copy:Operator Pink Copy:LEA ® ■ <br />