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Oa Waste Tire Sui vey & Inspection Report Inspection Report Number <br /> Cal Rec cle State of California <br /> Y CalRecycle 181(Rev.10/10) Survey Form - Page 1 I1 1 2 3 0 2 2 4 <br /> Dept.of Resources Recycling and Recovery(CalRecycle) <br /> Part A-Surve BLUE OR BLACK INK PEN_ <br /> Business Profile Inspection Details <br /> TPID- � � � b � Inspection Type(Fill one) <br /> Site Suffix: Routine Q Re-inspection Q Referral O Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier: SU.Y1 1-0 V 1,Y-11, Cv VI / Q CHP Q CalRecycle Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name I/ / Inspected By Inspector <br /> Physical Address <br /> IS o� �. C,�nac�6 VJc y <br /> tZI Inspection Date 1 / -211 / 1 <br /> Time In Time Out <br /> Business Rep Title e * AM I l 2 C 0 AM <br /> tll� Q PM 1 1 J ✓ 0 PM <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 /> /(2 Q Active Q Passenger Q Generator Q <br /> Ou1oo <br /> r <br /> Latitude O0 Closed Q Ater Q /jaRh- A <br /> GPS O Q Inactive Q TruA <br /> Longitude - Q Planned Q OTR Q End-Use Q Container <br /> Business Type(Fill all that apply) <br /> Q New Tire Dealer 0 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 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 <br /> 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 N <br /> Q Q 14 CCR§18459.2.1 -Submittal of Comprehensive Trip Logs within 90 days (Required for NOV or EX7) 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 /> 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 /> Comments,�, C�—', <br /> Inspection Form Included: Q �^ t J _3,7}i; <br /> Comments Included: Q !.� <br /> Business Rep's Signature Phone Number Inspe P or's Signature Phone Number <br /> INSTRUCTIONS ON BACK Correct:I, Incorrect: 1 NJ EXAMPLE 1 2 3 62081 <br /> 0 White Copy:CalRecycle Yellow Copy:Operator Pink Copy:LEA ® ■ <br />