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Waste Tire Sul, sey & Inspection Report Inspection Report Number <br /> State of California <br /> CalRecycle _ <br /> CalRecycle 181(Rev.10/10) Survey Form - Page 1 I1 1210156 <br /> Dept.of Resources Recycling and Recovery(CalRecycle) <br /> Part A-Survey BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- ' 1 Inspection Type(Fill one <br /> Site Suffix: -7 Routine 0Re-inspection Q Referral <br /> Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier: SaY. "TO V C�-3 Q CHP Q CalRecycle Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name y ' Inspected By Inspector <br /> D• C. Q. Mo 6 `j _ S�c�;cam 3 _ o <br /> Physical Address T v <br /> 301 L� <br /> Inspection Date / O Q / 1 3 <br /> l�a,��R-� C 015.3.36 <br /> Time In Time Out <br /> Business Rep Title 0 AM C 0 AM <br /> F ©G-�V�. 2— ' � O'0 PM J PM <br /> a Operational Status Tire Type Business Role Storage Type <br /> Tire Count(VUholTE <br /> (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> � � � <br /> 0 Active 0 Passenger + Generator Q Outdoor <br /> Q Closed Q Altered <br /> GPS Latitude Q Hauler Q Indoor <br /> 0 Q Inactive Q Truck <br /> Longitude — Q Planned Q OTR Q End-Use 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 Q Agriculture Q Shredder • 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 /> Q Q PRC§42956-Registration/Decal in Vehicle <br /> Q Q 14 CCR§18459-Responsible Entities Complying with Manifesting Requirements Date m / m / m <br /> Q Q 14 CCR§18459.1 -Tire Program ID Number from CalRecycle Cl) <br /> Q Q 14 CCR§18459.2.1 -Submittal of Comprehensive Trip Logs within 90 days (Required for NOV or EXT) n <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 /> 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 .In Compliance-No Violations o <br /> Q Q Other:§ <br /> Comments <br /> Inspection Form Included: Q p Ar �, a (� p• <br /> Comments Included: <br /> Business Flars Signature Phone Number Insp tor's Signature Phone Number <br /> —[ <br /> INSTRUCTIONS ON BACK rect: Incorrect: M� � E X A M P L E 1 2 3 62081 <br /> Cor <br /> White Copy:CalRecycle Yellow Copy:Operator Pink Copy:LEA <br />