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Inspection R:,�urt Number <br /> Waste Tire ��� vey & Inspection Repo. _ ■ <br /> CalRecycle State of cle181nia I"� - -1- 176,/-4-73`1e '1 7 �,7 3 <br /> CalRecycle 181(Rev.10/10) Survey Form - Page 1 11 =1 L <br /> Dept.of Resources Recycling and Recovery(CalRecycle) <br /> _BLUE OR BLACK INK PEN <br /> Part A-Survey <br /> Business Profile Inspection Details - - <br /> TPID- Inspection Type(Fill one) <br /> Site Suffix: Ll 5 C 1 C) 1 0 Routine 0 Re-inspection 0 Referral 0 Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier: �� '� ( \�� 0 CHP 0 CalRecycle 0 Complaint 0 Educational Visit 0 Other <br /> Business or Facility Name Inspected By Inspector <br /> LG}uvli <br /> Physical Address <br /> Inspection Date / l <br /> Time In Time Out <br /> Business Rep Title 0 AM 10 AM <br /> /� <br /> 0 PM V PM <br /> 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 /> 1j 0 Active 0 Passenger 0 Generator 0 Outdoor <br /> O 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 W Vr <br /> Part B- Inspection of Waste Tire Dealer, Generator, Hauler and End-Use Facility ENFORCEMENT STATUS <br /> V A HAULING AND MANIFEST REQUIREMENTS <br /> 0 Notice Of Violation 0 Extension <br /> 0 0 <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 /> 0 0 PRC§42956-Registration/Decal in Vehicle <br /> 0 0 14 CCR§18459-Responsible Entities Complying with Manifesting Requirements Date M / m / m <br /> 0 0 14 CCR§18459.1 -Tire Program ID Number from CalRecycle <br /> 0 0 14 CCR§18459.2.1 -Submittal of Comprehensive Trip Logs within 90 days (Required for NOV or EXT) — N <br /> n <br /> 0 0 14 CCR§18459.3-Retention of Comprehensive Trip Logs for 3 years o <br /> 0 0 14 CCR§18460.2-Manifest System Requirements for Registered Waste Tire Haulers 0 Referred/CalRecycle Enforcement <br /> 2 <br /> W <br /> 0 0 14 CCR§18461 -Manifest System Requirements for Waste Tire End-Use Facilities _ <br /> 0 0 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators ®In Compliance-No Violations o <br /> 0 0 Other:§ <br /> Comments <br /> ee 1 -/s <br /> Inspection Form Included: 0 <br /> Comments Included: <br /> MCop <br /> sines,Rep's Signature Phone Number ture Phone Number <br /> OE <br /> INSTRUCTIONS ON BACK Correct:* Incorrect: 1 26208White Copy:CalRecycle Yellow Copy:Operator ■ <br />