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M Waste Tire Sul, vey & Inspection Report ::ispection Report Number <br /> CalRecycle State of California 11 - 1177610 <br /> CalRecycle 181(Rev.10/10) Survey Form - Page 9 <br /> Dept.of Resources Recycling and Recovery(CalRecycle) <br /> BLUE OR BLACK INK PEN <br /> Part A-Survey <br /> Business Profile Inspection Details <br /> TPID- Inspection Type(Fill one) <br /> Site Suffix: O'Routine Q Re-inspection Q Referral Q Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier: ,� C V �V Q CHP Q CalRecycle Q Complaint Q Educational Visit Q Other <br /> Business(o`r Facility Name m Inspected By Inspector <br /> Physical Address J <br /> Inspection Date <br /> Y\ CAgS�IS <br /> Time In Time Out <br /> Business Rep TitleAM 'Al <br /> 1 pp�� <br /> n � ` • 0 O 0 P � 1 L ✓ QPM <br /> L 15Gti M , &ue ra, "+ry (fe►'' <br /> --- Operational Status Tire Type Business Role Storage Type <br /> Tire Count(Whole/PTE) 73 (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> • Active Q Passenger 0 Generator Q Outdoor <br /> 6 Q Closed Q Altered <br /> GPS Latitude Q Hauler 0Indoor <br /> o Q Inactive 0 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 10 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 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 /> 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 <br /> Q Q 14 CCR§18459.2.1 -Submittal of Comprehensive Trip Logs within 90 days (Required for NOV or EXT) N <br /> Q 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 /> Lu <br /> Lu <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 /> z <br /> Comments _0"_r <br /> �cex9.evS recce O (onkAyms VC's ��'2r COPCeC� <br /> 0 C I��Pllat S f3� CQ�nCQf�L <br /> Inspection Form Included: Q 6144, <br /> Comments Included: N�5—3yol �H6$-3Z$H <br /> Bu ss Rep's Signature Phone Number Insp tor's Signature Phone Number <br /> - - — <br /> INSTRUCTIONS ON BACK Correct:I, Incorrect: EXAMPLE 1112 3 62081 <br /> ■ White Copy:CalRecycle Yellow Copy:Operator Pink Copy:LEA ® ■ <br />