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Waste Tire Sw vey & Inspection Report Inspection Report Number <br /> cle State of California <br /> CalRecycle — <br /> Y CalRecycle 181(Rev.10/10) Survey Form - Page 1 I 1 1177720 <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: 5 ® Routine Q Re-inspection Q Referral Q Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier: ` �ocl�b�nl� �tM-�'] Q CHP Q CalRecycle Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name ( Inspected By Inspector <br /> Physical Address 1 3 <br /> J - <br /> Inspection Date '5 <br /> Time In Time Out <br /> Business Rep Title ® AM AM <br /> G d 0 PM 0 0 PM <br /> ��� CC•'l.Ct✓( 5 �� �� Operational Status Tire Type Business Role Storage Type <br /> Tire Count (Whole/PTE) 437 (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> ® Active Q Passenger ® Generator ® Outdoor <br /> O Q Closed Q Altered <br /> �PS Latitude Q Hauler 0 Indoor <br /> O Q Inactive (a 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 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 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 / 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 /> 2 <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 1 Q 1 Other:§ <br /> Comments ` <br /> u <br /> Inspection Form Included: Q G1 <br /> Comments Included: ® <br /> Wusinessps Signature Phone Number In ct 's Si tur -- Phone Number <br /> - 62081 <br /> INSTRUCTIONS ON BACK �Correct:e Incorrect: E X 1 2 3 <br /> ® White Copy:CalRecycle Yellow Copy:Operator Pink Co :L ® 0 <br />