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Waste Tire Survey & Inspection Report inspection Report Number <br /> State of California <br /> CalRecycle — <br /> CalRecycle 181(Rev.10/10) Survey Form - Page 1 I1 1230117 <br /> Dept.of Resources Recycling and Recovery(CalRecycle) <br /> Part A- Survey BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- ` O h S - © I Inspection Type(Fill one) <br /> Site Suffix: 0 Routine Q Re-inspection Q Referral Q Observation <br /> Localc f,- If Referral,choose referral type(Fill one) <br /> Identifier: Jho ID LL. 1411'N 6,kOQ CHP Q CalRecycle Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name I <br /> Inspected By Inspector <br /> C(,f�1\, l�n�ma u r o/\ 3 - 1 <br /> Physical Addr I csooT-ro <br /> 5_ EI QorCA <br /> Inspection Date 5 / D I / <br /> �� Time In Time Out <br /> Business Rep D Title O AM C O AM <br /> ` <br /> �A-�e, ` OtNaTS Pltt{l� mAil� �-, 0 5 0 PM � J � e 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 /> ® Active Q Passenger ® Generator Q Outdoor <br /> O Q Closed Q Altered N Aq <br /> GPS Latitude Q Hauler Q Indoor <br /> O Q Inactive ® 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 ® Other Awry l Fet4 1 p 1914 <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 EXT) N <br /> Q Q 14 CCR§18459.3-Retention of Comprehensive Trip Logs for 3 years <br /> N <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 Q 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators ®In Compliance-No Violations o <br /> Q Q Other:§ <br /> Commentstert�-- 14 \_ 1 <br /> �3.C11 `q1 WeJ/ �j�G �1Je. e lYl U��V^ 7 T'11S <br /> 1�Q_p��(( <br /> V1a1il LY1s (�I C1t f�uS ! (,�I1Cern, <br /> Inspection Form Included: Q <br /> Comments Included: ® <br /> Busine Rep Signa ren Number Insp tor's Signature Phone Number <br /> INSTRUCTIONS ON BACK I Correct: Incorrect: X EXAM E 112 3 62081 <br /> . White Copy:CalRecycle Yellow Copy:Operator Pink CopL <br />