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Waste Tire Survey & Inspection Repor ` Inspection Report Number <br /> CalRec cle State of California <br /> Y CalRecycle 181(Rev.10/10) 1 1245130 <br /> Dept.of Resources Recycling and Recovery(CalRecycle) Survey Form ® gage 1 <br /> BLUE OR BLACK INK PEN <br /> Part A-Survey <br /> Business Profile Inspection Details <br /> TPID- Inspection Type(Fill one) <br /> Site Suffix: ' v 1 0 V ®Routine Q Re-inspection Q Referral Q Observation <br /> Local �-`- , <br /> If Referral,choose referral type(Fill one) <br /> Identifier: 0 t 6l CuA Q CHP Q CalRecycle Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name Inspected By Inspector <br /> i ry-� ori j�rt�+ <br /> Physical Addrelss <br /> All pw <br /> Inspection Date <br /> IDTV "7�o <br /> CIS <br /> Time In Time Out <br /> Business Rep P`Imo, ITit�le 9 /� : 3 .yr *AM � 1 /� Q ® AM <br /> cbe i C'a-by Ly- a-- cL I Vl f en L if,csz ( (J [ O P M 1 � P M <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 /> 0 Active Q Passenger • Generator Q Outdoor <br /> - <br /> If <br /> o Q Closed Q Altered n1'9� , <br /> GPS Latitude Q Hauler Q Indoor <br /> o Q Inactive Q Truck <br /> Longitude — Q Planned ® OTR O 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 �(,Q!) `- <br /> Q Service Station Q Hauler p Agriculture Q Shredder !Other r`� ' K ko 0 ukdu 4. <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 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 <br /> Q Q 14 CCR§18459.2.1 -Submittal of Comprehensive Trip Logs within 90 days (Required for NOV or EXE N <br /> a <br /> Q O 14 CCR§18459.3-Retention of Comprehensive Trip Logs for 3 years o <br /> Q O 14 CCR§18460.2-Manifest System Requirements for Registered Waste Tire Haulers Q Referred/CalRecycle Enforcement <br /> 2 <br /> W <br /> Q O 14 CCR§18461 -Manifest System Requirements for Waste Tire End-Use Facilities <br /> Q O 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators S..In Compliance-No Violations o <br /> Q Q Other:§ <br /> Comments � <br /> Inspection Form Included: Q <br /> Comments Included:Included: <br /> Business p's Signature Phone Number Inspector's Signature Phone Number <br /> INSTRUCTIONS ON BACK Correct: Incorrect: IEIXIAIMIPILIEI 1112 3 62081 <br /> White Copy:CalRecycle Yellow Copy:Operator Pink Copy:LFA ® 0 <br />