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Waste Tire S&ey & Inspection Repo AInspection Report Number <br /> CalRec cle State of California — <br /> Y CalRecycle 181(Rev.10/10) Survey Form - Page 1 I1 1230058 <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„ / q Inspection Type(Fill one) <br /> Site Suffix: V 1 b 3 I 0 Routine Q Re-inspection Q Referral Q Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier: y-, �0 vjY\ ���� Q CHP Q CalRecycle Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name Inspected By Inspector <br /> o� � � LLC, 1 �\ <br /> Physio IAtldres0•� X74) - <br /> Inspection Date /^) <br /> CN 95�� <br /> t Time In lJ Time Out <br /> Business Rep Title O AM 1 O AM <br /> `PM ! Is O 0 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 /> I' Active Q Passenger Generator Q Ouv9or <br /> GPS Latitude 0 Q Closed Q Altered Q Hauler Q door <br /> O Q Inactive 0 Truck <br /> Longitude - Q Planned OTR Q End-Use Q Container <br /> Business Type(Fill all that apply) (eifApr <br /> Q New Tire Dealer Q Auto Repair 0 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 /> VT-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 <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 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 /> 2 <br /> Q Q 14 CCR§18461 -Manifest System Requirements for Waste Tire End-Use Facilities W <br /> O 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators .In Compliance-No Violations o <br /> Q Q Other:§ <br /> Comments1 `1"4(��_ <br /> 5 <br /> Inspection Form Included: Q Jss <br /> ts Included: BusinRep's Signature Phone Number Inspec is Signature Phone Number <br /> INSTRUCTIONS ON BACK Correct: Incorrect: X—47 EXAMPLE 1112 3 62081 <br /> White Copy:CalRecycle Yellow Copy:Operator Pink Copy:LEA <br />