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s <br />Waste Tire Survey & Inspection Report Inspection Report Number <br />CalRecycle State of California I 1- 123037.8 <br />CalRecycle 181 (Rev. 10/10)Survey Form -Page 1 <br />Dept of Resources Recycling and Recovery (CalRecycle) <br />)art A - Survey_ BLUE OR BLACK INK PEN <br />Business Profile Inspection Details <br />TPID - r , O 1 — Inspection Q <br />n Type (Fill one) <br />Site Suffix: "� Routine Re -inspection Referral Observation <br />Local If Referral, choose referral type (Fill one) <br />Identifier: 5 5d c1i �\Y\ Cpv V\ Q CHP Q CalRecycle Q Complaint Q Educational Visit Q Other <br />Business or Facility Name l Inspected By Inspector <br />MQ-cto- gam �� v�e� - c) <br />Physical Address <br />ZG� Inspection Date O / -7 / <br />Time In Time Out <br />Business Rep Title?, O AM 20 AM <br />V S ,,�� 1 J PM PM <br />^^ <br />1`�1(kC�O`I� �-ZY�S�Y,�f� <br />— -- - - ------ -�'—" �'- - Operational Status Tire Type Business Role Storage type <br />Tire Count (Whole/PTE) <br />2 q O (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br />0 Active 40 Passenger Generator Q Outdoor165 <br />o Q Closed Q Altered <br />GPS LatitudeQ Hauler Q Indoor 17.5 <br />o Q Inactive 4110 Truck <br />Longitude - Q Planned • OTR Q 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 ` <br />Q Service Station Q Hauler Q Agriculture Q Shredder • Other Mh+navte Si�w <br />Part <br />B - <br />Inspection of Waste Tire Dealer, Generator, Hauler and End -Use Facility <br />ENFORCEMENT STATUS <br />Q Notice Of Violation Q Extension <br />V <br />A <br />HAULING AND MANIFEST REQUIREMENTS <br />Q <br />Q <br />PRC § 42951 - Waste Tire Hauler Registration and Transport of Tires <br />Q <br />Q <br />PRC § 42953 - Contracts with Registered Waste Tire Haulers. <br />Compliance Deadline <br />Q <br />Q <br />PRC § 42956 - Registration/Decal in Vehicle <br />Q <br />Q <br />14 CCR § 18459 - Responsible Entities Complying with Manifesting Requirements <br />Date m / m <br />Q <br />Q <br />Q <br />Q <br />14 CCR § 18459.1 - Tire Program ID Number from CalRecycle <br />14 CCR § 18459.2.1 - Submittal of Comprehensive Trip Logs within 90 days <br />(Required for NOV or E)C7) <br />Q <br />Q <br />14 CCR § 18459.3 - Retention of Comprehensive Trip Logs for 3 years <br />Q <br />Q <br />14 CCR § 18460.2 - Manifest System Requirements for Registered Waste Tire Haulers <br />Q Referred / CalRecycle Enforcement <br />Q <br />Q <br />14 CCR § 18461 - Manifest System Requirements for Waste Tire End -Use Facilities <br />Q <br />Q <br />14 CCR § 18462 - Manifest System Requirements for Tire Dealers or Waste Tire Generators <br />le In Compliance - No Violations <br />Q <br />Q <br />Other: § <br />I- <br />- - — <br />Comments `1JC'S� 'Nyi QVc\ <br />Inspection Form Included: <br />Comments Included: <br />■ INSTRUCTIONS ON <br />dc? 970 971 <br />ess Rep's grh6re Phone Number <br />�K I Correct: 0 Incorrect: � W E <br />White Copy: CalRecycle Yellow Copy: Operator <br />IEIXIAIMIPILIEI 11123 <br />Pink Copy: LFA <br />8 <br />Phone Number <br />62081 <br />® N <br />