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Oa Waste Tire Su. oey & Inspection Report inspection Report Number <br /> C81Rec cle State of California — <br /> Y CalRecycle 181(Rev.10/10) Survey Form ® gage 1 I1 1242460 <br /> Dept of Resources Recycling and Recovery(CalRecycle) <br /> Part A-Survey BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- < I _ © I Inspection Type(Fill one) <br /> Site Suffix: J I * Routine Q Re-inspection Q Referral Q Observation <br /> Local �? If Referral,choose referral type(Fill one) <br /> Identifier: 50�n JQP1l6�;(� C01Jkn� Q CHP Q CalRecycle Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name Inspected By Inspector <br /> Physical Address - 01 C S";TT o <br /> Inspection Date '7 <br /> a Ate- c ' CA q 5331 Time In ((JJ Time Out <br /> Business Rep Title C 0 O AM AM <br /> ' `� ® PM PM <br /> � � � � <br /> Nei «a L wpb QVAJk m�r� <br /> Operational Status Tire Type Business Role Storage Type <br /> Tire Count (Whole/PTE) <br /> (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> � 5 <br /> 0 Active • Passenger ® Generator • Outdoor <br /> O Q Closed Q Altered <br /> G�� Latitude Q Hauler Q Indoor <br /> O Q Inactive Q Truck <br /> Longitude - Q Planned Q OTR Q End-Use • Container <br /> Business Type(Fill all that apply) <br /> o 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 4D 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 <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) <br /> _ a <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 /> 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:§ <br /> LL <br /> Comments <br /> Inspection Form Included: O n <br /> Comments Included: ® J � � ^� <br /> Bu ness Rep's Signature Phone Number In ctor's Signature Phone Number <br /> INSTRUCTIONS ON BACK Correct: Incorrect: X yj E X A M P L E 213 62081 <br /> White Copy:CalRecycle Yellow Copy:Operator Pink Copy: EA <br />