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Waste Tire Sui vey & Inspection Report Inspection Report Number ■ <br /> cle state of California <br /> CalRecycle — <br /> Y CalRecycle 181(Rev.10/10) SurveI 1 1210286 <br /> Dept.of Resources Recycling and Recovery(CalRecycle) Survey Form - Page 1 <br /> Part A-Survey BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- Inspection Type(Fill one) <br /> Site Suffix: ? <br /> ?j �j � `�"j ) � � � ® Routine Q Re-inspection Q Referral Q Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier: S�Vl -�0Ck Cb11-\\__'1. 60 VI/1- Q-CHP Q CalRecycle Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name Inspected By Inspector <br /> cep Com.\ P _ <br /> Physical Address �A+y145L)) A <br /> Inspection DateCA q5530 <br /> Time In Time Out <br /> Business Rep Titlel � � � O AM AM <br /> � � � <br /> PM Z 0 Q PM <br /> �rc�no� �2 ✓1 - <br /> l Operational Status Tire Type Business Role Storage Type <br /> Tire Count(Whole TE <br /> (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> � � �, d <br /> ® Active 0 Passenger IM Generator ® Outdoor <br /> Q Closed Q Altered <br /> GPS Latitude Q Hauler 46 Indoor <br /> O Q Inactive ® Truck <br /> Longitude - Q Planned OTR 0 End-Use ® 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 p6k'r- 11kn <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 Q PRC§42951 -Waste Tire Hauler Registration and Transport of Tires Q Notice Of Violation Extension <br /> Q Q PRC§42953-Contracts with Registered Waste Tire Haulers. Compliance Deadline <br /> PRC§42956-Registration/Decal in Vehicle <br /> QQ 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) <br /> a <br /> Q Q 14 CCR§18459.3-Retention of Comprehensive Trip Logs for 3 years <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 1 Other:§ <br /> Comments <br /> Inspection Form Included: Q Cok-orn' G� <br /> Comments Included: ® �Oq o�� 66 �W <br /> Business Rep's Signature Phone Numbersp tor' gn ure Phone Number <br /> 62081 <br /> INSTRUCTIONS ON BACK Correct: Incorrect: I EXAM 1 2 3 <br /> White Copy:CalRecycle Yellow Copy:Operator Pink Copy L <br />