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Waste Tire 5,,.. vey & Inspection Repork Inspection Report Number <br /> CalRecycle State of California I 1 - 1 2 4 5 2 0 8 <br /> CalRecycle 181(Rev.y(10) Survey Form - Page, 1 <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: 3 2 3 �` 'T U 0 Routine Q Re-inspection Q Referral Q Observation <br /> Local n If Referral,choose referral type(Fill one) <br /> Identifier: ; (:��'Ul C� Q CHP Q CalRecycle Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name <br /> Inspected By Inspector <br /> Physical Address <br /> C 3�t/ Inspection Date 7_ / 1 5 <br /> Time In Time Out <br /> Tt (0 <br /> VO <br /> Business Rep Title O AM fj O AM <br /> f I ✓ v 4) PM V O'PM <br /> Vat a Y'i yz 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 0 Passenger 0 Generator 0 Outdoor L <br /> O Q Closed Q Altered <br /> GPS Latitude Q Hauler ® Indoor If <br /> O Q Inactive '®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 O 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 ^Ui y, 71� <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 O PRC§42953-Contracts with Registered Waste Tire Haulers. Compliance Deadline <br /> PRC§42956-Registration/Decal in Vehicle <br /> QQ 14 CCR§18459-Responsible Entities Complying with Manifesting Requirements Date <br /> Q O 14 CCR§18459.1 -Tire Program ID Number from CalRecycle <br /> Q O 14 CCR§18459.2.1 -Submittal of Comprehensive Trip Logs within 90 days (Required for NOV or EXE N <br /> Q Q 14 CCR§18459.3-Retention of Comprehensive Trip Logs for 3 years <br /> Q Q 14 CCR§18460.2-Manifest System Requirements for Registered Waste Tire Haulers Q Referred/CalRecycle Enforcement <br /> 2 <br /> Q Q 14 CCR§18461 -Manifest System Requirements for Waste Tire End-Use Facilities _ W <br /> Q Q 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators ®In Compliance-No Violations o <br /> Q Q1 Other:§ <br /> Comments {� , , �"^�—� �L'!/)„�, �(.�, ( ✓�.Q.D?�. - A _,. �Q+�C�i CiYL �d <br /> i <br /> Inspection Form Included: Q <br /> Comments Included: <br /> L Y <br /> Business ep's Signature Phone Number nsp tor's sigmirrre Phone Number <br /> INSTRUCTIONS ON BACK I Correct:* Incorrect: R� v IEIXIAIMIPILIE1 2 3 62081 <br /> White Copy:CalRecycle Yellow Copy:Operator Pink Copy:LEA ® ■ <br />