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r <br /> Oa Waste Tire Sup vey & Inspection Report Inspection Report Number ■ <br /> CalRec cle State of California w <br /> Y CalRecycle 181(Rev.10/10) Survey Form - Pie 1 11 1177976 <br /> Dept.of Resources Recycling and Recovery(CalRecycle) <br /> Part A-Survey BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- © I Inspection Type(Fill one) <br /> Site Suffix: ` 1 lV g ® Routine 0 Re-inspection Q Referral Q Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier: �(���QC,(/,t \t:� Wu'(Niu Q CHP Q CalRecycle Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name _ 4 1 <br /> \ Inspected By Inspector <br /> Physical Address ) 5 I (9 1 CS`O-z <br /> 1 - <br /> �� ���O� Inspection Date � / 1 D / 1 DL <br /> Time In Time Out <br /> Business Rep Title 1 Q r 0 AM pp OO (DAM <br /> a� <br /> l KJ� • ' J Q PM 1 Q PM <br /> <<Jlk'M `'fc.5��� <br /> Operational Status Tire Type Business Role Storage Type <br /> Tire Count (Whole/PTE) 1 U Cj (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <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 Q Container <br /> Business Type(Fill all that apply) <br /> Q New Tire Dealer Q Auto Repair Q Trucking Fleet Q Government (3 Retreader 0 Dismantler Q Tire Derived Fuel <br /> ® 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 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 m m a <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 o <br /> Q Q 14 CCR§18460.2-Manifest System Requirements for Registered Waste Tire Haulers Q Referred/CalRecycle Enforcement <br /> Q Q 14 CCR§18461 -Manifest System Requirements for Waste Tire End-Use Facilities W <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 V�1��,Iri!li (��WS�Cc. rn i [.11�-r 1� (�O L� AIN AIN' i i_ CA Ina "f►1 (� <br /> LM fA <br /> Inspection Form Included: O <br /> Comments included: <br /> Business ep's Signatur Phone Number �1. p tor's SignatureC Phone Number <br /> INSTRUCTIONS ON BACK Correct 40 Incorrect: JEJXJA L El 111213 62081 <br /> White Copy:CalRecycle Yellow Copy:Operator Pink C y: ® 0 <br />