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Waste Tire Su, Bey & Inspection Repo rtonspection Report Number <br /> CalRecycle State of California — <br /> Y CalRecycle 181(Rev.10/10) Survey Form - Page 1 I1 1229925 <br /> Dept.of Resources Recycling and Recovery(CalRecycle) <br /> Part A -Survey <br /> BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- Inspection Type(Fill one) <br /> Site Suffix: , 5 O I* Routine Q Re-inspection Q Referral Q Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier: r �On GV ^ r Q CHP Q CalRecycle Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name v <br /> Inspected By Inspector <br /> - MAT <br /> -TO <br /> Address 39 1 O 1 / "M` A 1 Tv <br /> 16-2 <br /> �. �' Inspection Date /)v 1 ) s <br /> M.0-v\ `p""� Time In Time Out <br /> Business Rep Title O AM 7 O AM <br /> ` v ` _ �c <br /> Z : S S OPM C . S QPM <br /> S�C-o;- � ,I G�1� 0 W V'\e'� Operational Status Tire Type Business Role Storage Type <br /> Tire Count(Whole/PTE) (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> Q Active Q Passenger Q Generator Q,tOutdopr <br /> D Closed <br /> GPS Latitude Q Alte Q/Hau er Q Indoor <br /> 0 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 <br /> Q Service Station Q Hauler Q Agriculture Q Shredder a OtherS'y� �I <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 <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 m / m / m <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 EXE <br /> Q Q 14 CCR§18459.3-Retention of Comprehensive Trip Logs for 3 years <br /> 0 <br /> Q Q 14 CCR§18460.2-Manifest System Requirements for Registered Waste Tire Haulers Q Referred/CalRecycle Enforcement <br /> 2 <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 a In Compliance-No Violations o <br /> Q Q Other:§ <br /> Comments V %_ `YAP Inv C9V� Ni S <br /> yA s oC' v_c0-� cam- ChC-t-ro s <br /> Inspection Form Included: Q <br /> Comments Included: , <br /> usiness Re Signature Phone Number Inspec is Signature <br /> . Phone Number <br /> INSTRUCTIONS ON BACK Correct:* Incorrect: EXAMPLE 1 2 3 62081 <br /> White Copy:CalRecycle Yellow Copy:Operator Pink Copy:LEA <br />