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Waste Tire Survey a Inspection Report Insp ion Deport Number . <br /> CalRecycle State of cle 181(R I � _ �- 1 7 6 8 0 6 <br /> CalRecycle 181(Rev.10/10) Survey Form Page 1 11 .- <br /> Dept.of Resources Recycling and Recovery(CalRecycle) <br /> BLUE OR BLACK INK PEN <br /> Part A-Survey <br /> Business Profile Inspection Details <br /> TPID- Inspection Type(Fill one) <br /> Site Suffix: 3 q 3 I v 0 Routine Q Re-inspection Q Referral Q Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier: an J U Ul l f> (0 LAQ CHP Q CalRecycle Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name Inspected By Inspector <br /> 'L-ju'n5+AA _ GyU1 fi o . <br /> Physical Address 3 5 &n ESCI� <br /> Inspection Date / <br /> sate Time 1 l <br /> Time In Time Out <br /> Business Rep Title f e # AM 'AM <br /> I J O 0 P L ) Q 0 P <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 /> Q Active Q Passenger Q Generator Q Outdoor <br /> - - - O ® Closed Q AlteVd/4 ,v�i�f N�4 <br /> GPS Latitude Q Hauler Q Indoor <br /> O Q Inactive Q Truck <br /> Longitude - 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 /> Q Used Tire Dealer Q Auto Body Q Car Dealer Q Collection Q Crumb Rubber (�`l <br /> Q Service Station Q Hauler Q Agriculture Q Shredder Q Other I V(A <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 N <br /> Q Q 14 CCR§18459.1 -Tire Program ID Number from CalRecycle <br /> Q Q 14 CC (Required for NOV or EXT) <br /> R§18459.2.1 -Submittal of Comprehensive Trip Logs within 90 days <br /> N <br /> Q Q 14 CCR§18459.3-Retention of Comprehensive Trip Logs for 3 years <br /> Q Q Referred/CalRec cle Enforcement <br /> 14 CCR§18460.2-Manifest System Requirements for Registered Waste Tire Haulers Q y Lu <br /> Lu <br /> Q Q 14 CCR§18461 -Manifest System Requirements for Waste Tire End-Use Facilities --- <br /> Q O 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators <br /> in Compliance No Violations o <br /> Q Q Other:§ - <br /> Comments <br /> NAcS' SuS;MS� IS ton an Ir L4 4 n �Oi'i.+),Din <br /> u i A S. +C, f C4 )� (, i <br /> Inspection Form Included: Q V .309 <br /> Comments Included: Q <br /> Business Rep's Signature Phone Number �Inp�r'sSture Phone Number <br /> m 62081 <br /> INSTRUCTIONS ON BACK Correct:• Incorrect: (!� E X A P 112 3 ® ■ <br /> ■ <br /> Pink C <br /> White Copy:CalRecycle Yellow Copy:Operator o <br />