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Waste Tire SL_ trey & Inspection Report Inspection Report NumberState of <br /> ■ <br /> CalRecycle CalRecyclel' ia 181n(Rev.10/10) - 1196381 <br /> Dept.of Resources Recycling and Recovery(CalRecycle) <br /> Survey Form - Page 1 I1 <br /> part A- Survey BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- Inspection Type(Fill one) <br /> Site Suffix: _l 0 Routine Q Re-inspection Q Referral Q Observation <br /> Local ( ],_- If Referral,choose referral type(Fill one) <br /> C "u <br /> Identifier: oq<'\ J 4S ,n V�1�t1'1'IJJ� Q CHP Q CalRecycle Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name 1 Inspected By Inspector <br /> 3 1 n o <br /> Physical Address 9 - G 1 C 7T <br /> Inspection Date � / Q q / <br /> Po^ <br /> Time In Time Out <br /> Business Rep TitleD O �0 AM 0 AM <br /> Un �C.��Ul I ��lf cc��flLtl � PM a � � PM <br /> J 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 /> a, <br /> Active Q Passenger • 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 ® Container <br /> Business Type(Fill all that apply) <br /> Q New Tire Dealer Q Auto Repair A 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 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 <br /> 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 EXE <br /> a <br /> Q Q 14 CCR§18459.3-Retention of Comprehensive Trip Logs for 3 years <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 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 11 1i t 1 k <br /> No Of e._res�5 cry cam-,cern. <br /> Inspection Form Included: Q , <br /> Comments Included: ® `�it 16 ' <br /> Business Rep s�ynature Phone Number Ins ctor's Signature Phone Number <br /> INSTRUCTIONS ON BACK Correct:* Incorrect: M � E X A M L 1112131 62081 <br /> ■ White Copy:CalRecycle Yellow Copy:Operator Pink Copy:L �� ■ <br />