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Oa Waste Tire Survey & Inspection Report Inspection Report Number ■ <br /> CalRec cle State of California — <br /> Y CalRecycle 181(Rev.10/10) I 1 1242484 <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- ! C) Q V 3 _ ® I Inspection Type(Fill one) <br /> Site Suffix: 1 0 Routine Q Re-inspection Q Referral Q Observation <br /> Local C r If Referral,choose referral type(Fill one) <br /> Identifier: 7G^ ��t'1 t`� C�(J�{1� Q CHP Q CalRecycle Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name o Inspected By Inspector <br /> �'_(Ar s AIA ' 2 All r - ) J� <br /> Physical Address I v IS torr 0 <br /> ^ %VS Inspection Date <br /> U V ,i�J Time In Time Out 111 J <br /> Business Rep Title l 0 ®AM !t s AM <br /> ` V J V QPM lJ � v QPM <br /> U r� �U i�S cnti,,-� <br /> Operational Status Tire Type Business Role Storage Type <br /> Tire Count(Whole/PTE) 3 C) (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> J a Active Q Passenger ®Generator 0 Outdoor <br /> Q Closed O Altered <br /> GPS Latitude Q Hauler Q Indoor <br /> O Q Inactive Q Truck <br /> Longitude — O Planned O OTR O End-Use Q Container <br /> Business Type(Fill all that apply) <br /> New Tire Dealer ® 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 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 /> O O <br /> PRC§42951 -Waste Tire Hauler Registration and Transport of Tires <br /> Q 0 PRC§42953-Contracts with Registered Waste Tire Haulers. Compliance Deadline <br /> PRC§42956-Registration/Decal in Vehicle <br /> Q O 14 CCR§18459-Responsible Entities Complying with Manifesting Requirements Date <br /> M / M / m <br /> O O 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 EXE n <br /> O O 14 CCR§18459.3-Retention of Comprehensive Trip Logs for 3 years o <br /> O O 14 CCR§18460.2-Manifest System Requirements for Registered Waste Tire Haulers Q Referred/CalRecycle Enforcement <br /> O O 14 CCR§18461 -Manifest System Requirements for Waste Tire End-Use Facilities W <br /> O O 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators e In Compliance-No Violations o <br /> O O Othery:�§ <br /> Comments1'u-- <br /> �01�� ��hUJYAS 1n AJ - <br /> r <br /> Noy101AkV-,s Of CA'Jer,�,{ + concern, <br /> Inspection Form Included: 0.4 2 <br /> Comments Included: NTW f� lJLO <br /> Bu s ep's Signature Phone Number Insp or' <br /> ns Signature Phone Number <br /> INSTRUCTIONS ON BACK Correct: Incorrect: X � V I I E I X I A MI P E 1 2 3 62081 <br /> ■ White Copy:CalRecycle Yellow Copy:Operator Pink Copy: © ■ <br />