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02 Waste Tire Suuvay & Inspection Report Inspection Report Number <br /> CalRec cle State of California — <br /> Y CalRecycle 181(Rev.10/10) Survey Form — Page I1 1242188 <br /> Dept.of Resources Recycling and Recovery(CalRecycle) <br /> Part A-Survey _ BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- Inspection Type(Fill one) <br /> Site Suffix: c7` ® Routine Q Re-inspection Q Referral Q Observation <br /> Localc Ir If Referral,choose referral type(Fill one) <br /> Identifier: J�� �GG'Cibi' yy LG"6-'(./ Q CHP Q CalRecycle Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name !!! Inspected By Inspector <br /> Physical Address 3 <br /> AGO 1. t�ti(,i/�i/��:�� [.—+i l <br /> Inspection Date � •-7 / `� � / y �/ <br /> Time In / Time Out <br /> Business Rep Title ® AM ' l r 2 CAM <br /> N Q PM > � O PM <br /> 1,� <br /> ��' o ICs' S' kC_V__ Or,,�i I t&,a, . <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 /> ' ° ® Active ® Passenger a Generator a Outdoor <br /> O Q Closed Q Altered <br /> GPS Latitude Q Hauler Q Indoor <br /> 0 <br /> inactive I FOCK <br /> Longitude — Q Planned Q OTR Q End-Use Q Container <br /> Business Type(Fill all that apply) <br /> ® New Tire Dealer e 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 /> 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 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 <br /> Q Q 14 CCR§18459.2.1 -Submittal of Comprehensive Trip Logs within 90 days (Required for NOV or EXE 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 /> Lu <br /> Lu <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:§ <br /> Comments <br /> Inspection Form Included: Q f <br /> Comments Included:® yua_eA <br /> Business Rep's ure oris mber Insj5ecfor1s,$1gn7ture Phone Number <br /> 62081 <br /> INSTRUCTIONS ON BACK Correct: Incorrect: � W q E X JEJ 1112 3 <br /> ■ White Copy:CalRecycle Yellow Copy:Operator Pink C EA ® 0 <br />