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Waste Tire SUF vey & Inspection Report Inspection Report Number ■ <br /> Cal Rec cle State of California _ <br /> Y CalRecycle 181(Rev.10/10) Survey Form - Page 1 I1 1210150 <br /> Dept.of Resources Recycling and Recovery(CalRecycle) <br /> Sart A-Survey _ BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- � � � � � - O 1 I® Q- Inspection Type(Fill one) <br /> Site Suffix: 6 Routine Re-inspection Referral Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier: (jQQ ��y� c /v V"kQ CHP Q CalRecycle Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name L ` �/ <br /> Inspected By Inspector <br /> cJ-S Tr�hs�oc�C��:or 3 <br /> Physical Address <br /> \C>'72_(=) <br /> [ � 9 5330 Inspection Date CJ Q 5 <br /> O� Time In Time Out <br /> Business Rep ` �C , e 40 AM AM <br /> q S S 0 PM U 0 PM <br /> mm(k �r—coc►G <br /> Operational Status Tire Type Business Role Storage Type <br /> Tire Count(Whole/PTE) 3 (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> 0 Active Q Passenger 0 Generator • Outdoor <br /> O Q Closed Q Altered <br /> GPS Latitude Q Hauler Q Indoor <br /> O Q Inactive + Truck <br /> Longitude - Q Planned Q OTR Q End-Use Q Container <br /> Business Type(Fill all that apply) <br /> Q New Tire Dealer Q Auto Repair 0 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 Q Hauler Q Agriculture Q Shredder • Other ! (�C�\��\ \1(2A <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 Q PR - Q Notice Of Violation Q Extension <br /> C§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 N <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 /> Q Q 14 CCR§18459.3-Retention of Comprehensive Trip Logs for 3 years <br /> 0 <br /> Q Q 14 CCR§18460.2-Manifest System Requirements for Registered Waste Tire Haulers Q Referred/CalRecycle Enforcement <br /> uj <br /> W <br /> Q Q 14 CCR§18461 -Manifest System Requirements for Waste Tire End-Use Facilities <br /> Q O 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 <br /> 209-A?s-7P16z <br /> Comments Included: 0 - — <br /> Business Rep's Signature Phone Number Insp ctor's Signature Phone Number <br /> �-�( <br /> INSTRUCTIONS ON BACK Correct:* Incorrect: M � NJ EXAMPLE 1 2 3 62081 <br /> ■ White Copy:CalRecycle Yellow Copy:Operator Pink Copy:LEA LA ■ <br />