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Waste Tire Su,vey & Inspection Report*Inspection Report Number <br /> cle State of California <br /> CalRecycle Y CalRecycle 181(Rev.10/10) Survey Form - Page 1 I1 - 1177565 <br /> Dept.of Resources Recycling and Recovery(CalRecycle) <br /> Part A-Survey BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- (fir Inspection Type(Fill one) <br /> Site Suffix: 3 - l Q l ® Routine Q Re-inspection Q Referral Q Observation <br /> Local `w If Referral,choose referral type(Fill one) <br /> Identifier: �l� ����-�� Cy✓ � O CHP Q CalRecycle Q Complaint O Educational Visit Q Other <br /> Business or Facility Name y� ,,LL LLn,aa Inspected By Inspector <br /> cLvklAddress aS ��� - <br /> 3 Leto Cc. 11,'fr� <br /> K, (fA Inspection Date <br /> —" ��� Time In Time Out J <br /> Business Rep Title O AM _ O AM <br /> I ' ';2' 5— ® PM -7 & PM <br /> Alex. =z Auj,.�kwvt <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 /> ® Active .® Passenger ® Generator Q Outdoor <br /> Q Closed Q Altered <br /> GPS Latitude Q Hauler Q Indoor <br /> 0 Q Inactive Q Truck <br /> Longitude - Q Planned O OTR O 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 ® 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 Q 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 /> PRC§42956-Registration/Decal in Vehicle <br /> OO 14 CCR§18459-Responsible Entities Complying with Manifesting Requirements Date M / Fp / m <br /> N <br /> 0 O 14 CCR§18459.1 -Tire Program ID Number from CalRecycle � <br /> Q O 14 CCR§18459.2.1 -Submittal of Comprehensive Trip Logs within 90 days (Required for NOV or EXT) 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 Q 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 <br /> O O Other:§ <br /> Comments <br /> Inspection Form Included: Q <br /> Comments Included: <br /> Business Rep's Signature Phone Number s or's i ature Phone Number <br /> 62081 <br /> INSTRUCTIONS ON BACK Correct: Incorrect: X E1xjAjMj-P'jLjEj1 2 3 <br /> White Copy:CalRecycle Yellow Copy:Operator Pink Copy:LEA <br />