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® 02 Waste Tire Sut vey & Inspection Report nspection Report Number <br /> calRecycle State of California 11 - 1177856 <br /> CalRecycle 181(Rev.10/10) Survey Form - Page <br /> Dept.of Resources Recycling and Recovery(CalRecycle) BLUE OR BLACK INK PEN <br /> Part A-Survey - <br /> Business Profile Inspection Details <br /> TPID- ii - Inspection Type(Fill one) <br /> Site Suffix: I 01 ® Routine Q Re-inspection Q Referral Q Observation <br /> Local If Referral,choose referral type(Fill one) <br /> de tifier: S 0 t ��f 1 C()1/�n� Q CHP Q CalRecycle Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name Inspected By Inspector <br /> Physical AdreVU J 3 1 <br /> 303 � � wk�l�� til . - - - - <br /> t Inspection Date <br /> i 5to \,/L��� /(A J` Time In Time Out <br /> AM <br /> Title O AM I <br /> Business Rep 5 O PM 0 / T&PM <br /> Operational Status Tire Type Business Role Storage Type <br /> (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> Tire Count (Whole/PTE) (`� <br /> Active 0 Passenger � Generator � Outdoor <br /> PS Latitude O Q Closed Q Altered Q Hauler Q Indoor <br /> G <br /> O Q Inactive Q Truck <br /> Longitude - Q Planned Q OTR End Use Q 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 /> I® 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 Q 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 m m N <br /> Q Q 14 CCR§18459.1 -Tire Program ID Number from CalRecycle <br /> Q Q 14 CC (Required for NOV or EXE N <br /> R§18459.2.1 -Submittal of Comprehensive Trip Logs within 90 days a <br /> Q Q 14 CCR§18459.3-Retention of Comprehensive Trip Logs for 3 years <br /> Q Q Q Referred/CalRecycle Enforcement <br /> 14 CCR§18460.2-Manifest System Requirements for Registered Waste Tire Haulers 2 <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 19 In Compliance-No Violations o <br /> Q Q Other:§ -- - - - - <br /> Comments �t ]f� {/ 7 �/�d/��Ct [� 15 2 C.(� <br /> � <br /> �7 � <br /> 'Wj�j <br /> o -N) A4? V wc- s oncepo - <br /> Inspection Form Included: Q O'�� �"i 3 �-1 v 11rA <br /> Comments Included: ® / Inspect Signature <br /> Pho a Number <br /> Business Rep's Si ature Phone Number p s 9 <br /> 62081 <br /> INSTRUCTIONS ON BACK Correct:® Incorrect: � X A M E 1 2 3 <br /> ■ White Copy:CalRecycle Yellow Copy:Operator Pink Co ® ■ <br />