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Waste Tire Survey & Inspection Report inspection Report Number <br /> Cal Rec cle State of California - <br /> Y CalRecycle 181(Rev.10/10) Survey Form - Page 1 11 - 1177865 <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 � � � � � � _ © � Inspection Type(Fill one) <br /> Site Suffix: ` • Routine Q Re-inspection Q Referral Q Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier: G(11 C)/,L 1^ C01A f� Q CHP Q CalRecycle Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name Inspected By Inspector <br /> 5�6c�L+Un Ntlf)ss3 - 1 <br /> Physical Address ��L <br /> 30 r'-7 mrn*J' 1-0 . <br /> Inspection Date � / � 3 � 1 <br /> �CLtof-\ C Y} 1 SZ1 Z L <br /> Time In Time Out <br /> Business Rep Title O AM 0 AM <br /> `J1 3 3 O 0 PM <br /> ((��,, 1 3 d � OF PM A (��y,T�l�cr `ar75 C- <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 ' Passenger 0 Generator Q Outdoor <br /> O Q Closed Q Altered <br /> GPS Latitude Q Hauler 0 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 /> 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 <br /> Q Q 14 CCR§18459.1 -Tire Program ID Number from CalRecycle LS <br /> Q Q 14 CCR§ (Required for NOV or E)C7) N <br /> 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 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 <br /> .0 , 0 Other:§ <br /> Comments 9-01 f` 1 3 N <br /> NL o <br /> e <br /> o X01 ukA)���► ��s �a��' <br /> �p�' tells of <br /> Inspection Form Included: Q �(�d <br /> Comments Included: �I ��'�n <br /> 'Hess s nature Phone Number Inspe is Signature hone Number <br /> -- 62081 <br /> INSTRUCTIONS ON C t: Incorrect: E X A M P L E 1 2 3 <br /> White Copy:CalRecycle Yellow Copy:Operator Pink CC : <br />