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Waste Tire S ey & Inspection Repon Inspection Report Number <br /> CalRec cle State of California <br /> Y calRecycle181(Rev.10/10) Survey Form - Page 1 11 1245341 <br /> Dept.of Resources Recycling and Recovery(CalRecycle) <br /> Dart A-Survey BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- Q I Inspection Type(Fill one) <br /> Site Suffix: ( J -L ( '0 Routine Q Re-inspection Q Referral Q Observation <br /> Local C If Referral,choose referral type(Fill one) <br /> Identifier: JG ✓� �� CJ�iLQ CHP Q CalRecycle Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name Inspected By Inspector <br /> Physical Address <br /> Inspection Date ld f S <br /> C Time In Time Out <br /> Business Rep Title � � Q� PM i � s- 0 AM <br /> ` 41 PM i� i..✓.�+� <br /> U40 <br /> Operational Status Tire Type Business Role Storage Type <br /> Tire Count (Whole/PTE) (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> 10 ® Active Q Passenger I* Generator Q Outdo r <br /> C Q Closed Q Altered 71 <br /> GPS Latitude Q Hauler Q Indoor <br /> O Q Inactive � Truck <br /> Longitude - Q Planned 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 (� ga.k7 <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 - Q Notice Of Violation Q Extension <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 <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 /> a <br /> 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 /> 2 <br /> Lu <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 1<(;/Lc��.�'1'�.k• I,�ITGIId�t �,u-'2- I Ir✓Z�Lil-�..�'��Y� C%l(%Yt�t�� '�'`'�-'�' �l�Lc�f �, <br /> lltk <br /> I � � <br /> Inspection Form Included: Q <br /> Comments Included:'1101, <br /> 01�9 ` 3 3 -417 3 IAA—_--� <br /> Business Rep's Signature Phone Number nspector's Si re Phone Number <br /> INSTRUCTIONS ON BACK Correct:0 Incorrect: E X A M P L E 1 2 3 62081 <br /> ■ White Copy:CalRecycle Yellow Copy:Operator Pink Copy:LEA ■ <br />