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0 Waste Tire Su. vey & Inspection Repoft Inspection Report Number <br /> cal Rec cle State of California — <br /> Y CalRecycle 181(Rev.10/10) Survey Form - Page I1 1230240 <br /> Dept.of Resources Recycling and Recovery(CalRecycle) <br /> Part A-Survey BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- -7 � � � � � O � Inspection Type(Fill one) <br /> Site Suffix: b 9 Routine Q Re-inspection Q Referral Q Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier: v Q CHP Q CalRecycle Q Complaint Q Educational Visit Q Other <br /> Cx'IBusiness or Facility Name \/ Inspected By Inspector <br /> Physical Address <br /> LA 10 51 96 Vnio <br /> Inspection Date <br /> 5� C� aS2o3 »I <br /> (� Time In Time Out <br /> Business Rep I°iie AM <br /> V. „may- ' 1 . ', 5 Z Q PM� � �® � PM <br /> �. <br /> S� VLZ Operational Status Tire Type Business Role Storage Type <br /> (Fill rogl4 (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> Tire Count (Whole/PTE) � � � <br /> Ac ive Q Passenger Q <br /> Ger Q�O <br /> udo <br /> r <br /> o Closed Q A)?r � er . <br /> GPSLatitude - Q Indoor <br /> OQ Inactive Q Tru � <br /> Longitude <br /> - Q Planned Q 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 /> Op 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 /> Q Q PRC§42956-Registration/Decal in Vehicle <br /> QQ 14 CCR§18459-Responsible Entities Complying with Manifesting Requirements Date m / <br /> Q Q 14 CCR§18459.1 -Tire Program ID Number from CalRecycle N <br /> Q Q 14 CCR§18459.2.1 -Submittal of Comprehensive Trip Logs within 90 days (Required for NOV or Exr) 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 /> Uj <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:§ <br /> � z <br /> Comments �S �lDW\tom WAS Y',C44• N <br /> aCGV\r'ec <br /> C0 \ <br /> Inspection Form Included: Q - — <br /> Comments Included: Q <br /> B s Rep's Signature Phone Number Insp ctor's Signature Phone Number <br /> INSTRUCTIO BACK [Correct:0 Incorrect: X a� VIIEIXIAIMIPILIEI 1112 3 62081 <br /> ■ White Copy:CalRecycle Yellow Copy:Operator Pink Copy:LFA ® ■ <br />