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Waste Tire Sup vey & Inspection Report Inspection Report Number ■ <br /> State of California <br /> CalRecycle <br /> CalRecycle 181(Rev.10/10) Survey Form - Page 1 I1 - 1226625 <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: i L� lj 5 C e Routine Q Re-inspection Q Referral Q Observation <br /> LocalIf Referral,choose referral type(Fill one) <br /> Identifier: 5 w� <br /> (XA Ss� �� Co Q CHP Q CalRecycle Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name Inspected By Inspector <br /> Physical Address <br /> C015 S, 4E) bvr�c_�c> >4__ - <br /> n /�/ Inspection Date 1 /J / o ci <br /> :SVD: _I `- cJY1 (-,A (��7-"G Time In Time Out <br /> l l Il <br /> Business Rep Title ®AM AM <br /> �LW�CV�; � QST � Vrr)'ZG �lC�l�. O O PM I � � � O PM <br /> Operational Status Tire Type Business Role Storage Type <br /> (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> Tire Count (Whole/PTE) <br /> 3 ® Active 0 Passenger a Generator ® Outdoor <br /> GPS <br /> Latitude Q Closed Q Altered Q Hauler Q Indoor <br /> O Q Inactive 4P Truck <br /> Longitude - Q Planned Q OTR Q End-Use Q Container <br /> Business Type(Fill all that apply) <br /> Q New Tire Dealer 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 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 /> 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 EXn 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 /> f <br /> W <br /> O O <br /> 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 <br /> See <br /> l0 <br /> Inspection Form Included: Q <br /> ori � - <br /> Comments Included: <br /> B in Rep' n ure Phone Number8�1 I p Wigture Phone Number <br /> INSTRUCTIONS ON Correct* Incorrect: X62081� � X A L E 1 2 3 <br /> White Copy:CalRecycle Yellow Copy:Operator Pink Copy:LEA ■ <br />