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0 Waste Tire Sui vey & Inspection Report Inspection Report Number <br /> CalRecycle State of California <br /> CalRecycle 181(Rev.10/10) Survey Form - Page 1 I1 1230243 <br /> Dept.of Resources Recycling and Recovery(CalRecycle) <br /> Part A-Survey BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- Z / Inspection Type(Fill one) <br /> Site Suffix: V 1 + Routine Q Re-inspection Q Referral Q Observation <br /> Local �^ If Referral,choose referral type(Fill one) <br /> Identifier: J� Ia(r � Q CHP Q CalRecycle Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name Inspected By Inspector <br /> GcczS `��c>zS Sec �;C� <br /> Physical Address - l 1 AT 1 <br /> (A Inspection Date 1 2 / O L) � l <br /> Time In Time Out <br /> Business Rep Title 0 AM 0 AM <br /> 1 � � � PM � � � 40 PM <br /> ar ; �o ct`e.5 )r-e�- <br /> cv— -- Operational Status Tire Type Business Role .Storage Type <br /> Tire Count(Whole T ) 2 (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> 7 0 Active • Passenger 4j Generator 4D Outdoor <br /> o Q Closed Q Altered <br /> �PS Latitude 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 Q 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 /> 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 <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 EXT) N <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 /> 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 /> Comments W ASK 1 � Asc� < <br /> � ? ��•o\a V"ON65 cc � ea_s 0�� C©v`c1c 1, <br /> Inspection Form Included: Q 2,0 <br /> _ d•d � /M ^� O_Y t f l� <br /> Comments Included. <br /> u s Rep's Signature Phone Number Inspec is Signature Phone Number <br /> INSTRUCTIONS ON BACK Correct:0 Incorrect: X747q]IEIXIAIMIPILIEI 11 2 3 62081 <br /> ■ White Copy:CalRecycle Yellow Copy:Operator Pink Copy:LEA ® . <br />