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03' Waste Tire Sup vey & Inspection Report `Inspection Report Number ■ <br /> CalRecycle State of California _ 11 - 1226650 <br /> CalRecycle 181(Rev.10/10) Survey Form Page 1 <br /> Dept of Resources Recycling and Recovery(CalRecycle) <br /> Part A-Surve _ -___ __ BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- Inspection Type(Fill one) <br /> Site Suffix: 'J O L 9� © 10 Routine Q Re-inspection Q Referral Q Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier: .5��(� �OCt�jv\� C�xM'�1 Q CHP Q CalRecycle Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name V Inspected By Inspector <br /> CCAS A cc, f-l ee�-- � 1 c�� `=( - '^ <br /> Physical Address <br /> KJ<��� <br /> j � 7� Inspection Date <br /> L.-C�.��n✓L`� C ` ""330 Time In l Time Out <br /> Business Rep <br /> Title 0 AM AM <br /> _ 5 V PM <br /> Q '5- � Q PM <br /> ley 'Q 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 Q Passenger ® Generator ® Outdoor <br /> O Q Closed Q Altered <br /> GPS Latitude S Hauler Q Indoor <br /> O Q Inactive ® Truck <br /> Longitude - Q Planned Q OTR it End-Use Q Container <br /> Business Type(Fill all that apply) <br /> Q New Tire Dealer Q 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 e Hauler Q Agriculture Q Shredder 0 Other �1�� e�e�ssi� RS <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 /> 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:§ - a <br /> Comments <br /> r` N <br /> V <br /> ocl <br /> Inspection Form Included: QComments Included B ess Rep's Signa Phone Number nt Phone Number <br /> 62081 <br /> 1NSTRUCTlpNS N BACK Corre t: Incorrect: ® � X 1 2 3 <br /> ■ White Copy:CalRecycle Yellow Copy:Operator Pink Copy:LFA, ® ■ <br />