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02 Waste Tire St ey & Inspection Reporonspection Report Number <br /> Cal Rec cle State of California <br /> Y CalRecycle 181(Rev.10/10) Survey Form - Page 1 11 - 1176656 <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: t 3 S (S Routine Q Re-inspection Q Referral Q Observation <br /> Local C If Referral,choose referral type(Fill one) <br /> Identifier: c7Gvy.ic�C�.�u Q CHP Q CalRecycle Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name U Inspected By Inspector <br /> e•4 keg Gr s ,��i r) f <br /> Physicaiddress 3 / a ( QO,C R:-I`1 Fs' <br /> Inspection Date ' Q <br /> yr �SZI`S <br /> Time In Time Out <br /> Business Rep Title ` D : S * AM I � 0 AM <br /> rr,, Rum <br /> f Q PM ® PM <br /> fk;�_ ort vm 13''a raru/", <br /> Operational Status Tire Type Business Role Storage Type <br /> Tire Count (Whole/PTE) ' j (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> ® Active Q Passenger ® Generator Q Outdoor <br /> O Q Closed Q Altered <br /> GPS Latitude Q Hauler ® 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 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 Q Other <br /> Part B - Inspection of Waste Tire Dealer, Generator, Hauler and End-Use Facility ENFORCEMENT STATUS <br /> V A iHAUL 146AND 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 <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 <br /> Q 14 CCR§18459.3-Retention of Comprehensive Trip Logs for 3 years o <br /> Q Q 14 CCR§18460.2-Manifest System Requirements for Registered Waste Tire Haulers Q Referred/CalRecycle Enforcement <br /> f <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 /> 10 O Other:§ <br /> Comments &Ad. � ,*,,o- <br /> Inspection Form Included: Q <br /> Comments Included: 1/ v�//2 <br /> Business Rep's Signature tone Number Inspector's Signature Phone Number <br /> 62081 <br /> INSTRUCTIONS ON BACK Correct: Incorrect: n E X A M L E 1 2 3 <br /> White Copy:CalRecycle Yellow Copy:Operator Pink Cop L <br />