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Waste Tire .'-. ey & Inspection Repoiwspection Report Number <br /> State of California <br /> CalRecycle 11 - 1176508 <br /> CalRecycle 181(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 /> Site Suffix: ( 3 3 3 7 Z <br /> ® Routine O Re-inspection O Referral O Observation <br /> Local 1 If Referral,choose referral type(Fill one) <br /> Identifier: O CHP O CalRecycle O Complaint O Educational Visit O Other <br /> Business or Facility Name V <br /> Inspected By Inspector <br /> Physical Address -3 f <br /> 1�-za Mc <br /> r Inspection Date / ( <br /> CA ) <br /> � I <br /> scct� 1 '3- I <br /> Time In Time Out <br /> Business(Rep t`c Title �y ® AM O AM <br /> ( 1Wn/�- 1�CP�IGkVYc'� /�ss� � PM � O� � � ® PM <br /> Operational Status Tire Type Business Role Storage Type <br /> Tire Count (Whole/PTE) / (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> i ® Active ® Passenger ® Generator ®Outdoor <br /> O O Closed O Altered <br /> GPS Latitude O Hauler ® Indoor <br /> O O Inactive O Truck <br /> Longitude - O Planned O OTR O End-Use (a Container <br /> Business Type(Fill all that apply) <br /> ® New Tire Dealer O Auto Repair O Trucking Fleet O Government O Retreader O Dismantler O Tire Derived Fuel <br /> ® Used Tire Dealer O Auto Body O Car Dealer O Collection O Crumb Rubber <br /> O Service Station ® Hauler O Agriculture O Shredder O Other <br /> Part B - Inspection of Waste Tire Dealer, Generator, Hauler and End-Use Facility ENFORCEMENT STATUS – <br /> _ HAULING ANDMAN-IF--ES—T REQUIREMENTS er - - ---- -- i— -- — - -- <br /> O Notice Of Violation O Extension <br /> O O PRC <br /> Wasteration 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 <br /> O O 14 CCR§18459.1 -Tire Program ID Number from CalRecycle <br /> O O 14 CCR§18459.2.1 -Submittal of Comprehensive Trip Logs within 90 days (Required for NOV or EXE N <br /> O O 14 CCR§18459.3-Retention of Comprehensive Trip Logs for 3 years <br /> O O 14 CCR§18460.2-Manifest System Requirements for Registered Waste Tire Haulers O Referred/CalRecycle Enforcement <br /> O O 14 CCR§18461 -Manifest System Requirements for Waste Tire End-Use Facilities W <br /> O O 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators ®In Compliance-No Violations o <br /> O O Other:§ <br /> Comments 1 <br /> 1 )�A/fd kal <br /> Inspection Form Included: O' <br /> Comments Included: ® C � V46 Ory 3 <br /> Business Rep's Signature Phone Number Inspector's Signature Phone Number <br /> Zdt <br /> 62081 <br /> INSTRUCTIONS ON BACK [Correct_ <br /> Incorrect' X J E I X I A JIM E 1 2 3 <br /> White Copy:CalRecycle Yellow Copy:Operator Pink Cop L <br />