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Waste Tire Sultey & Inspection Repoill <br /> InspectionReport Number <br /> CelRec cle State of California — —] ■ <br /> Y CalRecycle 181(Rev.10/10) Survey Form - Page 1 1226265 <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: 02 6 / Q Routine Q Re-inspection Q Referral Q Observation <br /> LocalC If Referral,choose referral type(Fill one) <br /> .Identifier: �]C:l , �L,)� Cc.Y�yL Q CHP Q CalRecycle Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name Inspected By Inspector <br /> Physical <br /> Street } aEv]Inspection Date � <br /> L-7_ CLCA <br /> I <br /> City State�J ZIP Code <br /> u Time In Time Out <br /> Business Rep Title ® AM1;1O AM <br /> o Q PM © o O PM <br /> I I I Operational Status Tire Type ' p 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) U I I I I I f ' <br /> Q Active Q Passenger Generator ;Q Outdoor - <br /> � ® Closed QAltered�- 5• <br /> Latitude. m x 3 <br /> GIPS # a ��w; Q Hauler eQlndoor�� ;: <br /> Q Inactive <br /> Longitude - F T F Q Planned �Q/OTR : y Q End-Use Y'Q'Contarner= <br /> Business Type(Fill all that apply) <br /> 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 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 Q aQ Notice Of Violation .Q .Extension <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 DateIf <br /> m m m <br /> Q 014 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 <br /> Q Q 14 CCR§ 18459.3-Retention of Comprehensive Trip Logs for 3 years <br /> N <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 0 14 CCR§18462- Manifest System Requirements for Tire Dealers or Waste Tire Generators ®In Compliance-No Violations or <br /> Comments Lv' NAk, `S�rl �o if l -Ain L/L&_,alz&- s _ klQdiCS E) <br /> SLSI't c b CLI C64 t <br /> -Io' _ W <br /> l- e - -"Ace <br /> Inspection Form Included: Q <br /> Comments Included: Q <br /> Business Rep's Signature Phone Number In pec 's i a re Phone Number <br /> 62081 <br /> INSTRUCTIONS ON BAFhite <br /> CorWCalRecycle <br /> orrect: t � E X AMP L E 1 2 3 <br /> Copy: Yellow Copy:Operator Pink Copy:LEA ® ■ <br />