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Waste Tire Survey & Inspection Report Inspection Report Number <br /> State of California <br /> CalRecycle <br /> CalRecycle 181(Rev.10/10) 1210438Survey Form - Page 1 I1 <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: S Routine 0 Re-inspection 0 Referral 0 Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier: 5 u^ l ' �j��� C()un�� 0 CHP 0 CalRecycle 0 Complaint 0 Educational Visit 0 Other <br /> Business or Facility Name` 1 �J�1 Inspected By Inspector <br /> Physical Address <br /> Inspection Date 7 / 0 <br /> CA 4SZ61D <br /> Time In Time Out <br /> Business Rep Title M �^ S AM c 10 AM <br /> k 0 3- O QPM I I � J QPM <br /> M - - -- Operational Status Tire Type Business Role Storage Type <br /> Tire Count(Whole/PTE) /5( (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> ® Active 0 Passenger ® Generator 0 nOutdoor <br /> O 0 Closed 0 Altered °V <br /> GPS Latitude <br /> O 0 Inactive 0 Truck 0 Hauler 0 Indoor <br /> Longitude - 0 Planned 0 OTR 0 End-Use 0 Container <br /> Business Type(Fill all that apply) <br /> 0 New Tire Dealer 0 Auto Repair 0 Trucking Fleet 0 Government 0 Retreader 0 Dismantler 0 Tire Derived Fuel <br /> Used Tire Dealer U Auto Body Car Dealer Collection Crumb RubEer <br /> 0 Service Station 0 Hauler 0 Agriculture 0 Shredder ® Other <br /> Part B - Inspection of Waste Tire Dealer, Generator, Hauler and End-Use Facility ENFORCEMENT STATUS <br /> V1 A I HAULING AND MANIFEST REQUIREMENTS <br /> 0 0 - 0 Notice Of Violation 0 Extension <br /> PRC§42951 Waste Tire Hauler Registration and Transport of Tires <br /> 0 0 PRC§42953-Contracts with Registered Waste Tire Haulers. Compliance Deadline <br /> PRC§42956-Registration/Decal in Vehicle <br /> 00 14 CCR§18459-Responsible Entities Complying with Manifesting Requirements Date m / m / M <br /> 0 0 14 CCR§18459.1 -Tire Program ID Number from CalRecycle <br /> 0 0 14 CCR§18459.2.1 -Submittal of Comprehensive Trip Logs within 90 days (Required for NOV or EXT) N <br /> a <br /> 0 0 14 CCR§18459.3-Retention of Comprehensive Trip Logs for 3 years <br /> 0 0 14 CCR§18460.2-Manifest System Requirements for Registered Waste Tire Haulers 0 Referred/CalRecycle Enforcement <br /> LU <br /> 0 0 14 CCR§18461 -Manifest System Requirements for Waste Tire End-Use Facilities _ W <br /> 0 0 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators <br /> f,In Compliance-No Violations o <br /> 0 0 Other:§ <br /> i <br /> Comments n � <br /> C) <br /> ay�o ��i <br /> nspec ion Fort ffWWuded: 0 -/` R� <br /> Comments Included: I$ <br /> Business s ignature Phone Number Inspec 's Signature hone umber <br /> INSTRUCTIONS ON BACK C rect:� Incorrect: � � q EXAM L E 1 2 3 62081 <br /> ® White Copy:CalRecycle Yellow Copy:Operator Pink Co :L ® ■ <br />