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Waste Tire Su. vey & Inspection Report Inspection Report Number <br /> C81Rec cle State of California <br /> Y CalRecycle 181(Rev.10/10) Survey Form ® Page 1 11 - 1177739 <br /> Dept.of Resources Recycling and Recovery(CalRecycle) <br /> Part A-Survey BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- / ��-y} ) Inspection Type(Fill one) <br /> Site Suffix: L �p C7� ( C�L C 0 Routine 0 Re-inspection 0 Referral 0 Observation <br /> Local SIf Referral,choose referral type(Fill one) <br /> Identifier. _CHP 0-CalRecycle_Q_Complaint—Q_Educational_V_isit-Q_Other_- <br /> Business or Facility Name Inspected By Inspector <br /> Phys&ddress u <br /> R93 �- C1e vch, z, <br /> Inspection Date �� / ) _3 <br /> Time In Time Out <br /> Business Rep Title 0 AM 7 0 AM <br /> ^� L� PM .! PM <br /> "Skekc)Cy. So '�X <br /> Operational Status Tire Type Business Role Storage Type <br /> Tire Count (Whol TE) (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> l �✓ ® Active go Passenger 0 Generator 0 Outdoor <br /> 0 0 Closed 0 Altered <br /> GPS Latitude 0 Hauler 0 Indoor <br /> O 0 Inactive 0 Truck <br /> Longitude - 0 Planned 0 OTR 0 End-Use 0 Container <br /> Business Type(Fill all that apply) <br /> 0 New Tire Dealer 0 Auto Repair 0 Trucking Fleet 0 Government 0 Retreader 0 Dismantler 0 Tire Derived Fuel <br /> 0 Used Tire Dealer 0 Auto Body 0 Car Dealer 0 Collection 0 Crumb Rubber <br /> 0 Service Station 0 Hauler 0 Agriculture 0 Shredder 0 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 /> O 0 § - - ®Notice Of Violation � Extension <br /> PRC 42951 Waste Tire Hauler Registration and Transport of Tires <br /> 0 0 PRC.§42953-Contracts with Registered Waste Tire Haulers. Compliance Deadline <br /> PRC§42956-Registration/Decal in Vehicle <br /> 00 14 CCR§18459-Responsible Entities Complying with Manifesting Requirements Date 5,1 / F/0 / F/E <br /> 0 0 14 CCR§18459.1 -Tire Program ID Number from CalRecycle N <br /> 0 0 14 CCR§18459.2.1 -Submittal of Comprehensive Trip Logs within 90 days (Required for NOV or EXE <br /> 0 0 14 CCR§18459.3-Retention of Comprehensive Trip Logs for 3 years <br /> 0 <br /> 0 0 14 CCR§18460.2-Manifest System Requirements for Registered Waste Tire Haulers 0 Referred/CalRecycle Enforcement <br /> LU <br /> 0 0 14 CCR§18461 -Manifest System Requirements for Waste Tire End-Use Facilities W <br /> 0 0 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators 0 In Compliance-No Violations o <br /> 0 1 0 Other:§ <br /> Comments <br /> Inspection Form Included: <br /> Comments Included: ® '(• <br /> Business Rep's Signature Phone Number 0464POignature Phone Number <br /> INSTRUCTIONS ON BACK Correct:IS Incorrect: � W EXAMPLE 1 2 3 62081 <br /> White Copy:CalRecycle Yellow Copy:Operator Pink Co : <br />