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Waste Tire Su, vey & Inspection Report inspection Report Number ■ <br /> CalRecle State of California <br /> cycle CalRecycle 181(Rev.10/10) Survey Form - Page 1 I1 - 1242386 <br /> Dept.of Resources Recycling and Recovery(CalRecycle) <br /> Part A-Survey BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- Q 1 - O 1 Inspection Type(Fill one) <br /> Site Suffix: ` 0 Routine Q Re-inspection Q Referral Q Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier: SQ,� �QV� (`v�V / Q CHP Q CalRecycle Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name ' - ` 'f Inspected By Inspector <br /> LS�or� Nw es-% S '�ic�Z Q��kittiS M A'� U <br /> Physical ddress <br /> 13 36 'o CV_ L0.�� CA4r—, ZOO <br /> Inspection Date O 7 <br /> Som gS2o6 <br /> Time In Time Out <br /> Business Rep Title40 AM 1 O AM <br /> �. O O O PM 1 0 PM <br /> Operational Status Tire Type Business Role Storage Type <br /> (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> Tire Count (Whole/PTE) ?j <br /> O Active Passenger . Generator 0 Outdoor <br /> Q Closed Altered <br /> GPS Latitude Q Hauler 9 Indoor <br /> 0 Q Inactive Truck <br /> Longitude - Q Planned ' OTR 0 End-Use 0 Container <br /> Business Type(Fill all that apply) <br /> New Tire Dealer Q Auto Repair Q Trucking Fleet Q Government 00 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 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 /> 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 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 /> w <br /> Q 9 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 IS In Compliance-No Violations o <br /> Q Q Other:§ <br /> Comments �� � �LL•, c�,� V. ���5���-,�f�� '[Y�e <br /> C� <br /> Inspection Form7lnc]1,uded:Commentd: y /yy��` c=lam <br /> Bu n s R ignature Phone Number Inspector's Signature Phone Number <br /> 62081 <br /> INSTRUCTIONS ON BACK Correct:10 Incorrect: X4 q EXAMPLE 1112 3 <br /> ■ White Copy:CalRecycle Yellow Copy:Operator Pink Copy:LEA ® ■ <br />