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Waste Tire Survey & Inspection Report Inspection Report Number <br /> CalRecycle State of California <br /> CalRecycle 181(Rev. 11 1244903 <br /> Deptof Resources Recycling and Recovery(CalRecycle) Srvey Form <br /> Part A-Survey BLUE OR BLACK INK PEN_ <br /> Business Profile Inspection Details <br /> TPID- Inspection� LA <br /> � � _ 0 � Inspection Type(Fill one) <br /> Site Suffix: 10 Routine Q Re-inspection Q Referral Q Observation <br /> Local , / If Referral,choose referral type(Fill one) <br /> Identifier: � O �I n 21ut Q CHP Q CalRecycle Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name ``-- Q (� Inspected By Inspector <br /> L�-, VAC cc1e�fel YL \t1rk5 C�i't', c�/f1�1t1C - _ <br /> Physical Address Lo-� I. <br /> Inspection Date <br /> oIXCs�O� LFl `�SZDS I <br /> Time In Time Out <br /> Business Rep Title 1 : O AM O AM <br /> �] D <br /> 1M i �1 cr t 1U+7� itf�t�t Ja s a PM ' S A PM <br /> Operational Status Tire Type Business Role Storage Type <br /> Tire Count (Whole/PTE) `� Q (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> J 9 Active 0 Passenger 0 Generator ® Outdoor <br /> 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 Q Retreader If 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 /> 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 EX7) 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 /> Q Q 14 CCR§18461 -Manifest System Requirements for Waste Tire End-Use Facilities W <br /> Q i0 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators <br /> ®In Compliance-No Violations o <br /> Q Q Other:§ <br /> Comments �i t �� N <br /> Inspection Form Included: <br /> Comments Included Z03� 31 <br /> Business Rep's Si ature Phone Number nsp or's Signature Phone Number <br /> INSTRUCTIONS ON BACK Correct:0 Incorrect: E X A L E 1 2 3 62081 <br /> ■ White Copy:CalRecycle Yellow Copy:Operator Pink CUK © 0 <br />