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Waste Tire Sui vey & Inspection Report Inspection Report Number ■ <br /> Cal Rec cle State of California <br /> Y CalRecycle 181(Rev.10/10) Survey Form - Page 1 I1 1226212 <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 Type(Fill one) <br /> Site Suffix: 1 3 -7 6) -7 D l • Routine Q Re-inspection Q Referral O Observation <br /> Local � ` ^ `_� If Referral,choose referral type(Fill one) <br /> Identifier: ` �-C) Q CHP Q CalRecycle 0 Complaint Q Educational Visit Q Other <br /> Business or Facility Name Inspected By Inspector <br /> C �,1 bvfL+s�Cr"- S PPO 3 - �A <br /> Physical Address t (�J' � bUt� <br /> ^ ��}} Inspection Date <br /> ✓�c.l,►A,��-_C `� t A "1533 c <br /> Time In Time Out <br /> Business Rep ( Title �/� 40 AM o AM <br /> AIICL✓l /�L �� �{�_ O PM 0 � � �� QPM <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 /> aActive ® Passenger ® Generator Q Outdoor <br /> O Q Closed Q Altered <br /> GPS Latitude Q Hauler I ® Indoor <br /> O Q Inactive O Truck <br /> Longitude - O Planned O OTR O End-Use Container <br /> Business Type(Fill all that apply) <br /> 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 ® 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 0 Extension <br /> O O PRC§42951 -Waste Tire Hauler Registration and Transport of Tires <br /> O O PRC§42953-Contracts with Registered Waste Tire Haulers. Compliance Deadline <br /> O O PRC§42956-Registration/Decal in Vehicle <br /> O O 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 0 <br /> O O 14 CCR§18459.2.1 -Submittal of Comprehensive Trip Logs within 90 days (Required for NOV or EXE N <br /> a <br /> N <br /> 0 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 /> Lu <br /> O O 14 CCR§18461 -Manifest System Requirements for Waste Tire End-Use Facilities ..... <br /> Q O 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators ®In Compliance-No Violations o <br /> Q Q Other:§ z <br /> Comments <br /> GCan M,54A, C <br /> Inspection Form Included: Q <br /> �`(•�a�.3-114 <br /> Comments Included: 0 <br /> Business R�Correct: <br /> p's Signature Phone Number I p t S' n ure Phone Number <br /> INSTRUCTIONS ON BACK 0Incorrect: ® � E X A M 1 2 3 62081 <br /> ® White Copy:CalRecycle Yellow Copy:Operator Pink Copy: ® ■ <br />