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2 Waste Tire Sui vey & lnsp cU a n Repue�f Inspection Report Number <br /> CalRecycle State of California <br /> CalRecycle 181(Rev.10/10) 11 m 1242181 <br /> Dept.of Resources Recycling and Recovery(CalRecycle) Su V®y Form <br /> , Page <br /> Part A-Survey BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- Inspection Type(Fill one) <br /> 1+ 7 — <br /> Site Suffix: / / - <br /> 1 � [ 1 E� � ( ® Routine Q Re-inspection Q Referral Q Observation <br /> Localc „ ��` l� L�4 If Referral,choose referral type(Fill one) <br /> Identifier: _]�•i 'LL Q CHP Q CalRecycle Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name Inspected By Inspector <br /> Phy)Address �� /�� L/�r <br /> `�J <br /> Inspection Date <br /> Time In Time Out <br /> Business Rep Title 40 AM AM <br /> V_�Lv14;-L ✓ J �. S Q PM O PM <br /> ���� •t��� fVc1.J �ti1.,a)�f.� <br /> Operational Status Tire Type Business Role Storage Type <br /> Tire Count (Whole/PTE) � l (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> V Q Active ® Passenger Q Generator Q Outdoor <br /> PS o11r <br /> G <br /> Latitude O 19 Closed Q Altered 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 /> ® New Tire Dealer ® Auto Repair Q Trucking Fleet Q Government Q Retreader Q Dismantler Q Tire Derived Fuel <br /> 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 /> VA 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 <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 EX7) n <br /> Q Q 14 CCR§18459.3-Retention of Comprehensive Trip Logs for 3 years <br /> Q Q 14 CCR§18460.2-Manifest System Requirements for Registered Waste Tire Haulers Q Referred/CalRecycle Enforcement <br /> LU <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 /> -- z <br /> CommentsI ` <br /> /' Q {// i14Y1�eflttn / (�'CJ ,•vt fi!/Iz\ cr��� 8/0 J'b A <br /> is koc.�__k /if(/_1 r)(2 P 41,0 /i, <L /'I <br /> r' / 6% I-% J/ <br /> `'per <br /> Inspection Form Included: Q / o <br /> Comments Included: Q <br /> Business Rep's 51g Phone Number 4npqk400�rX�' 6Sioature Phone Number <br /> INSTRUCTIONS ON BACK I Correct: Incorrect: NJ EXAM LjEj 1112 3 62081 <br /> White Copy:CalRecycle Yellow Copy:Operator Pink Copy:LEA ® 0 <br />