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Waste Tire Survey & Inspection Report Inspection Report Number <br /> CalRec cle State of California _ <br /> Y CalRecycle 181(Rev.10/10) Survey Form - Page 1 11 1242465 <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 Inspection Type(Fill oie) <br /> Site Suffix: (4 ® Routine Q Re-inspection Q Referral Q Observation <br /> LocalIf Referral,choose referral type(Fill one) <br /> Identifier: ��n J O(ALS X1 r\ C�ur� lA Q CHP Q CalRecycle Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name 1 _1 Inspected By Inspector <br /> '-�9 \toseM��c, vL,ySu;►� �O 3 _ <br /> PiysicalAddress l CSco7(To <br /> &L (4LLa <br /> Inspection Date <br /> L���snQ (,A cis3D <br /> Time In Time Out <br /> Business Rep Title ® O AM u j O AM <br /> h 1 aPM 1 l Q ® PM <br /> ►`i �1®*1 Ct csru f o1 C��r1 PJ` <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 /> Q Active Q <br /> Passenger Q Generator 0 O <br /> utdoo <br /> r <br /> O9 Closed Q Altefse� / O <br /> GPSLatitude 0Q Inactive Q Truck �ue� � dor <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 1 1 4w wL- r <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 <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 EXE n <br /> Q Q 14 CCR§18459.3-Retention of Comprehensive Trip Logs for 3 years <br /> 0 <br /> Q Q 14 CCR§18460.2-Manifest System Requirements for Registered Waste Tire Haulers Q Referred/CalRecycle Enforcement <br /> ul <br /> W <br /> Q Q 14 CCR§18461 -Manifest System Requirements for Waste Tire End-Use Facilities <br /> Q Q 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators In Compliance-No Violations o <br /> Q Q Other:§ <br /> Comments t �' �( <br /> 'V Jc- 11) t �L 11 it � <br /> AA <br /> 4- rQl <br /> o <br /> Inspection Form Included: _ <br /> Comments Included: - LIe4- 7 <br /> Busi s Rep's Signature Phone Number Insp tor's Signature Phone Number <br /> 62081 <br /> INSTRUCTIONS ON BACK Correct:* Incorrect: X EXAMPLE 1 2 3 <br /> White Copy:CalRecycle Yellow Copy:Operator Pink Copy:LEA <br />