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2 Waste Tire Survey & Inspection Report :rlspection Report Number ■ <br /> CalRecycle State of California <br /> Y CalRecycle 181(Rev.10/10) Survey Form - Page 1 11 - 1245063 <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 Inspection Type(Fitt one) <br /> Site Suffix: ` _` 10 Routine Q Re-inspection Q Referral Q Observation <br /> Local / If Referral,choose referral type(Fill one) <br /> Identifier: �n U� / TQ CHP Q CalRecycle Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name W Inspected By Inspector <br /> l'-ire 1 O A4 V <br /> Physical Address <br /> C Inspection Date <br /> 45kocvkDY-\ Time In Time Out <br /> Business Rep Title 3 0 AM J O AM <br /> • ✓ v , PM ` 0 PM <br /> �s�f.orn t2;2�av� <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 /> �u *Active * Passenger S Generator 40 Outdoor <br /> Q Closed Q Altered <br /> GPS Latitude Q Hauler Q Indoor <br /> O Q Inactive Q Truck <br /> Longitude - Q Planned Q OTR O End-Use Q Container <br /> Business Type(Fill all that apply) <br /> 10 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 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 PRC§42951 -Waste Tire Hauler Registration and Transport of Tires <br /> Q Q PRC§42953-Contracts with Registered Waste Tire Haulers. Compliance Deadline <br /> 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 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 /> 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 Q Other:§ <br /> Comments us` �� <br /> o'04 <br /> �- r <br /> Inspection Form Included: Q 6'l -cJ 1 <br /> Comments Included: r <br /> _ Bus Hess R p S' nature Phone Number Inspe is Signature Phone Number <br /> �( <br /> INSTRUCTIONS ON BACK Correct:0 Incorrect: X tt �J 11 EIXIAIMIP JLJEJ 1112 3 62081 <br /> ■ White Copy:CalRecycle Yellow Copy:Operator Pink Copy:LEA ® 0 <br />