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1. <br /> 02 Waste Tire S'-,vey & Inspection Repoi . Inspection Report Number ■ <br /> Cal Rec cle State of California <br /> Y CalRecycle 181(Rev.10/10) Survey Form - Page 1 I1 - 1176813 <br /> Dept.of Resources Recycling and Recovery(CalRecycle) <br /> Part A- Survey _ __ _. BLUE OR-BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- Inspection� C{ / � Q - q` I Inspection Type(Fill one) <br /> Site Suffix: 11 D V * Routine Q Re-inspection Q Referral Q Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier: SQA 7(��IA [411 1) �OL�(1�� Q CHP Q CalRecycle Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name l Inspected By Inspector <br /> g,u� 's Cant��A� enc . <br /> Physical Address <br /> INS S - <br /> I`3�D Inspection Date <br /> Time In Time Out <br /> Business Rep Title i 0 AM ] S O AM <br /> PM — CJS --J—O PM <br /> Nurl� plc {Y1U n U ej <br /> —1�- -- Operational Status Tire Type Business Role Storage Type <br /> /1 <br /> Tire Count(Whole/PTE) (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> `J <br /> le Active ® Passenger 41 Generator ® Outdoor <br /> O Q Closed O Altered <br /> GPS Latitude Q Hauler ® Indoor <br /> O Q Inactive ® Truck <br /> Longitude - O Planned 0 OTR 0 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 O Shredder ® Other COn4fu���I <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 /> O O <br /> PRC§42951 -Waste Tire Hauler Registration and Transport of Tires <br /> Q O 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 / m <br /> Q O 14 CCR§18459.1 -Tire Program ID Number from CalRecycle <br /> Q O 14 CCR§18459.2.1 -Submittal of Comprehensive Trip Logs within 90 days (Required for NOV or EXE N <br /> a <br /> Q Q 14 CCR§18459.3-Retention of Comprehensive Trip Logs for 3 years o <br /> O Q 14 CCR§18460.2-Manifest System Requirements for Registered Waste Tire Haulers Q Referred/CalRecycle Enforcement <br /> O 0 14 CCR§18461 -Manifest System Requirements for Waste Tire End-Use Facilities W <br /> Q O 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators (�In Compliance-No Violations o <br /> 0 O Other:§ <br /> Comments nl j�I 1�1 - 1l` �n5 f 1� On l- a047 <br /> X11 ow�n� no�ul; <br /> Inspection Form Included: Q <br /> Comments Included: --- -- --- -- <br /> B ess ep's Signatur Phone Number Insp tor's Signature Phone Number <br /> - - _- � 62081 <br /> INSTRUCTIONS ON BACK C rrect: Incorrect: X � I C X A M P L E - 111273 <br /> ■ White Copy:CalRecycle Yellow Copy:Operator Pink Copy:LEA © ■ <br />