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2 Waste Tire Survey & Inspection Report Inspection Report Number ■ <br /> Cal Recycle State of California I 1 - 1226678 <br /> CalRecycle 181(Rev.10/10) Survey Form - Page 1 <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- 1 r� u Inspection Type(Fill one) <br /> Site Suffix: i v l - I ® Routine Q Re-inspection Q Referral Q Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier: <br /> S 4o J DLL�( 1,{,lrl (,0l,tr) � Q CHP Q CalRecycle Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name L Inspected By Inspector <br /> ss <br /> \��( l Q-f ILI <br /> Physical Address <br /> 'Y�5 5 <br /> /� � C � Inspection Date l 10 <br /> `' `�` Time In Time Out <br /> Business Rep Title ` ` AM AM <br /> Q Q O PM ` . 150 O PM <br /> ---- - — - Operational Status Tire Type Business Role Storage Type <br /> Tire Count(Whole/PTE) 1 Q (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> l ® 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 Planned Q OTR Q End-Use Q Container <br /> Business Type(Fill all that apply) _ <br /> ® New Tire Dealer 0 Auto Repair Q Trucking Fleet Q Government Q Retreader Q Dismantler Q Tire Derived Fuel <br /> Q Used Tire Dealer Q Auto Body ® Car Dealer Q Collection Q Crumb Rubber <br /> 0 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 / 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 EXT) N <br /> r <br /> N <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 /> 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:§ ]1 1 <br /> Comments , n�__ <br /> ��ll \J <br /> eAS <br /> No Vi d I iUn5 (7) u,l.'_uc b+ 1 A)n Ca rn- <br /> Inspection Form Included: Q <br /> Comments Included. ® ✓ <br /> Business Rep's Signature Phone Number Inspec s Signature one Number <br /> 62081 <br /> INSTRUCTIONS ON BACK Correct:® Incorrect: � E X A P L 1 2 3 <br /> ■ White Copy:CalRecycle Yellow Copy:Operator Pi op ® ■ <br />