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0 2 Waste Tirel*rvey & Inspection Re 4aspection Report Number <br /> CalRecycle State of California _ <br /> CalRecycle 181(Rev.10/10) I1 1242306 <br /> Dept.of Resources Recycling and Recovery(CalRecycle) Survey Form - Page 1 <br /> Part A-Survey BLUE OR BLACK INK PEN_ <br /> Business Profile Inspection Details <br /> TPID- t-1 n1 .^ _ ft\ I Inspection Type(Fill one) <br /> Site Suffix: l V e� lJ Q Routine Q Re-inspection Q Referral Q Observation <br /> Local ` e If Referral,choose referral type(Fill one) <br /> Identifier: U� 0 aw1 r1 Q CHP Q CalRecycle Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name l <br /> Inspected By Inspector <br /> 2� <br /> Physical Address 3 - 1 b l Cs t 0 TT o <br /> Osco rT,r q AVS-, , f <br /> Inspection Date / G <br /> Time In Time Out <br /> Business Rep Title O AM O AM <br /> 1 ' U • PM C7 i PM <br /> - - Operational Status Tire Type Business Role Storage Type <br /> Tire Count (Whole/PTE) r,, (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> ® Active 40 Passenger 0 Generator Q Outdoor <br /> O Q Closed Q Altered <br /> GPS Latitude Q Hauler Q Indoor <br /> o Q Inactive Q Truck <br /> Longitude - Q Planned Q OTR Q End-Use 40 Container <br /> Business Type(Fill all that apply) <br /> ® New Tire Dealer ® 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 /> PRG§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 EXT) N <br /> Q * 14 CCR§18459.3-Retention of Comprehensive Trip Logs for 3 years <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 I, 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators ®In Compliance-No Violations o <br /> Q Q1 Other:§ <br /> Comments <br /> G <br /> Inspection Form Included: Q <br /> 7100 9 V - <br /> Comments Included: <br /> Business Rep's Signature Phone Number Insp or's Signature Phone Number <br /> INSTRUCTIONS ON BACK Correct',0 Incorrect: � � (� EXAM L 1 2 3 62081 <br /> White Copy:CalRecycle Yellow Copy:Operator Pink Copy: E ■ <br />