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Waste Tire Su. vey & Inspection Repori,,. Inspection Report Number ■ <br /> Cal Rec cle State of California <br /> Y CalRecycle 181(Rev.10/10) Survey Form - Page 1 I1 -1176777 <br /> Dept.of Resources Recycling and Recovery(CalRecycle) <br /> ')art A- Survey_ BLUE OR BLACK INK_ PEN <br /> Business Profile Inspection Details <br /> TPID- inspection Type(Fill one) <br /> Site Suffix: V f) Routine Q Re-inspection Q Referral Q Observation <br /> Local n If Referral,choose referral type(Fill one) <br /> Identifier: ����`�e/�� 1�, Q CHP Q CalRecycle Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name U 111 Inspected By Inspector <br /> C:If ki L—:-f� = <br /> Physical Address 3 <br /> Inspection Date (�i / O 1 <br /> Time In "7 Time Out <br /> Business Rep Title O AM I O AM <br /> IC f f : 0 0 PM PM <br /> � � GU��<<t ®�� IVB -- -- ---- - <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 /> Q Active Q P/asennger Q Generator Q Outdoor d <br /> O ® Closed Q Altered �/ ///A <br /> GPS Latitude Q Hauler Q Indoor <br /> 0 Q Inactive Q 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 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 Q Hauler Q Agriculture Q Shredder ® Other J <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 /> Q Q PRC§42956-Registration/Decal in Vehicle <br /> Q Q 14 CCR§18459-Responsible Entities Complying with Manifesting Requirements Date 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 EJC7) n <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 /> W <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 <br /> �,n�•�—,i:. 1 1 VLA 9 r��'v� ✓I F'.l f�1-vf'1 c'c C� "-i 1�1 1 X',r.�. � <lLf c� <br /> A I-E-AC!CT_Z_ r�I!'_ C�C c Un 1- t' rt t1Z c' -III t 1 <br /> Inspection Form Included: Q <br /> Comments Included: Q- --- --- ---- - - --- � - � <br /> usmess Rep's nature Phone Number _ s ec or' g atur Phone Number <br /> 62081 <br /> INSTRUCTIONS ON BACK <br /> [Correct:* Incorrect: ( IiE XrA M P rL I I I 1 12 3 <br /> ■ White Copy:CalRecycle Yellow Copy:Operator Pink Copy:LEA �� ■ <br />