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--------------- <br /> 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 - 1210461 <br /> Dept of Resources Recycling and Recovery(CalRecycle) <br /> Part A-SurVe BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- n r� � t� _ Inspection Type(Fill one) <br /> � Q <br /> Site Suffix: a[ I ! j ® Routine Q Re-inspection Q Referral Q Observation <br /> Local , If Referral,choose referral type(Fill one) <br /> Identifier: �(1I(( (,�(�U )f) Co u Q CHP Q CalRecycle Q Complaint Q Educational Visit Q Other <br /> Business OrFacilityName (( Inspected By Inspector <br /> ' �i U n s�vit� �vP� 3Physical �( inli <br /> dress <br /> L11'�u'yY FC-r r ' <br /> � <br /> CA S3 Inspection Date <br /> Time In Time Out <br /> Business Rep Title l J� O AM O AM <br /> 9, ' 1 0 ® PM � � � ePM <br /> QUreer• ( lint a ch J-- <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 ® Outdoor <br /> Q Closed Q Altered <br /> GPS Latitude Q Hauler Q Indoor <br /> O Q Inactive ® 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 ® 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 Q Other <br /> Part B - Inspection of Waste Tire Dealer, Generator, Hauler and End-Use Facility ENFORCEMENT STATUS <br /> V I A I HAULING AND MANIFEST REQUIREMENTS <br /> - ----- Q Notice Of Violation Q Extension <br /> Q Q PRC§42951 -Waste Tire Hauler Registration and Transport of Tires <br /> Q Q PRC§42953-Contracts with Registered Waste Tire Haulers. Compliance Deadline <br /> Q Q 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 N <br /> Q Q 14 CCR§18459.2.1 -Submittal of Comprehensive Trip Logs within 90 days (Required for NOV or EXT) <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 /> 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 1 Other:§ <br /> Comments 11 - _„�;� W-0� 1 ' <br /> 0�1.Jbw 1�, _ _ �L I+ <br /> 'Mn CA 1-(AS <br /> Inspection FormIncluded: •(;'O �������J�l� <br /> Comments Included: <br /> nes Rep"s-s"IMM Phone Number Insp c or's Signature Phone Number <br /> ,-,( <br /> INSTRUCTIONS ON BACK Correct: Incorrect: �J EXAM 112 3 62081 <br /> White Copy:CalRecycle Yellow Copy:Operator Pink Copy: <br />