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Waste Tire Su. ✓ey & Inspection Report Inspection Report Number <br /> CalRecycle State of California I 1 - '12 2 6 6 5 8 <br /> CalRecycle 181(Rev.10/10) Survey Form - Page 1 <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- ` q 1 Inspection Type(Fill one) <br /> Site Suffix: 1 Cp �Q 4 " 1 1 Q Routine ' Re-inspection Q Referral Q Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier: Q CHP Q CalRecycle Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name Inspected By Inspector <br /> --�(- <'�5 �Cs <br /> Physical Address <br /> ado gti,�c)jr) uI?,- <br /> Inspection Date <br /> ��GL6ATime In Time Out <br /> Business Rep TitleAM 10 AM <br /> II''�� /� 2 <br /> t 1 V o O PM ' I J O 0 PM <br /> �OS tl A I U.i1N.A• <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) v <br /> Active 40 Passenger I* Generator Q Outdoor <br /> Q Closed Q Altered <br /> GPS Latitude � Hauler if Indoor <br /> O Q Inactive Q Truck <br /> Longitude - Q Planned Q OTR Q End-Use Q Container <br /> Business Type(Fill all that apply) _ <br /> (a New Tire Dealer Q Auto Repair Q Trucking Fleet Q Government Q Retreader Q Dismantler Q Tire Derived Fuel <br /> ® Used Tire Dealer Q Auto Body Q Car Dealer Q Collection Q Crumb Rubber <br /> Q Service Station S 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 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 <br /> Q Q 14 CCR§18459.1 -Tire Program ID Number from CalRecycle <br /> Q Q 14 CCR§18 - (Required for NOV or EXT) <br /> 459.2.1 Submittal of Comprehensive Trip Logs within 90 days <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 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:§ L1 } <br /> Comments P(aJI p1A,� 1 (Y�(YJc�� i�i�( l� n��l71 P� o(1 (0 <br /> k V ,�Ia�;o�s htiv� bee�, eol(ctjVo6. <br /> Inspection Form Included: Q -log A nggt )Alt <br /> Comments Included: J <br /> B iness p's Signature Phone Number Inspe is Signature Phone Number <br /> - - �( <br /> INSTRUCTIONS ON BACK Correct:0 Incorrect: M � rJ E X A M L E 1 2 3 62081 <br /> ■ White Copy:CalRecycle Yellow Copy:Operator Pink Copy:LEA © ■ <br />