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2 Waste Tire Su. ,✓ey & Inspection Report Inspection Report Number <br /> CalRecycle State of California I 1 - 1210338 <br /> CalRecycle181(Rev.10/10) Survey Form - Page 1 <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 /> 1 <br /> Site Suffix: 1 1 0 7 D 7S 7 0 ' 0 Routine Q Re-inspection Q Referral Q Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier: V;Y-\ Q CHP Q CalRecycle Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name Inspected By Inspector <br /> ,(- � N � 1O1Physical SdcA&' M A T <br /> T v <br /> Inspection Date 6 I C / 1 3 <br /> Time In Time Out <br /> Business Rep TitleC� u AM AM <br /> I 1 S Q PM O 2 S O PM <br /> T red►oh <br /> Operational Status Tire Type Business Role Storage Type <br /> Tire Count(Whole/PTE) 2( (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> �U Q Active Q Passenger Q Generator Q Outdoor <br /> O • Closed Q Altered <br /> GPS Latitude Q Hauler Q Indoor <br /> O Q Inactive Q 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 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 <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 <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 /> PRC§42956-Registration/Decal in Vehicle <br /> Q Q 14 CCR§18459-Responsible Entities Complying with Manifesting Requirements Date m / m / m <br /> Q Q 14 CCR§18459.1 -Tire Program ID Number from CalRecycle a <br /> Q Q 14 CCR§18459.2.1 -Submittal of Comprehensive Trip Logs within 90 days (Required for NOV or EXE 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 Q 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators •In Compliance-No Violations o <br /> Q 1 Q Other:§ <br /> Comments <br /> rh'm .S �a <br /> e <br /> CI�L«�%��_�t�„�S_ � ��t► c �� PC\��C cl S��\rti_� �+ti.S_7�t- <br /> Inspection Form Included: QQ s - _ � '��, �� ✓J �- y <br /> Comments Included: " �r<-=�,VC-!)� y1-�'`'EJ— <br /> Busine Rep's Ign to Phone Number Inspe or's Signature Phone Number <br /> INSTRUCTIONS ON BACK Correct: Incorrect: E X A M P L E 1 2 3 62081 <br /> White Copy:CalRecycle Yellow Copy:Operator Pink Copy:LEA <br />