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d <br /> Waste Tire Survey & Inspection Report {'Inspection Report Number ■ <br /> CalRecycle state of California I 1 - 1210500 <br /> CalRecycle 181(Rev.10/10) Survey Form - Page 1 <br /> Dept.of Resources Recycling and Recovery(CalRecycle) <br /> Part A-Survey BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- b 5 - Q inspection Type(Fill one) <br /> Site Suffix: ® Routine Q Re-inspection Q Referral Q Observation <br /> LocalIf Referral,choose referral type(Fill one) <br /> C j <br /> Identifier: cx n J 6tAJ&'1 CCS u.n L_ Q CHP Q CalRecycle Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name Inspected By Inspector <br /> 0s50m Fit m S 3 - Q ESLb�Y� <br /> Physical Address <br /> Sic e�k�� CA �S��Z Inspection Date S I 3 <br /> Time In Time Out <br /> Business Rep Title � 5' 0 0 AM <br /> ® PM 3 1 AM O 0 P <br /> Operational Status Tire Type Business Role Storage Type <br /> Tire Count (Whole/PTE) 16 (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> ' ® Active ® Passenger If Generator • Outdoor <br /> O Q Closed Q Altered <br /> GPS Latitude Q Hauler Q Indoor <br /> O Q Inactive ® Truck <br /> Longitude - Q Planned 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 <br /> Q Service Station Q Hauler Is 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 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 /> PRC§42956-Registration/Decal in Vehicle <br /> Q Q 14 CCR§18459-Responsible Entities Complying with Manifesting Requirements Date m / Ifl / m <br /> Q Q 14 CCR§18459.1 -Tire Program ID Number from CalRecycle a <br /> Q Q 14 CCR§18459.2.1 -Submittal of Comprehensive Trip Logs within 90 days (Required for NOV or EXE <br /> _ a <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 /> Uj <br /> Q Q 14 CCR§18461 -Manifest System Requirements for Waste Tire End-Use Facilities W <br /> Q Q 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators <br /> In Compliance No Violations o <br /> Q 1 Q 1Other:§ _ <br /> - z <br /> Comments <br /> — 1 cA 0 <br /> 0�10 v\,3 A rl VJyt5 (low <br /> N1 I <br /> Inspection Form Included: Q i <br /> Comments Included: <br /> Business Rep's Signature Phone Number Inspe t is Signature Phone Number <br /> INSTRUCTIONS ON BACK I Correct: Incorrect: 7 EXAM P L 1112 3 62081 <br /> ® White Copy:CalRecycle Yellow Copy:Operator Pink Cop : <br />