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Waste Tire Suivey & Inspection Report Inspection Report Number <br /> CalRec cle State of California — <br /> Y CalRecycle 181(Rev.10/10) Survey Form - Page 1 I1 1230139 <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 r� - O Inspection Type(Fill one) <br /> Site Suffix: ` b 6 Routine 0 Re-inspection 0 Referral 0 Observation <br /> Local ► � If Referral,choose referral type(Fill one) <br /> Identifier: �1����q�/1�� u 0 CHP 0 CalRecycle 0 Complaint 0 Educational Visit 0 Other <br /> Business or Facility Name 1 1 l Inspected By Inspector <br /> Physical Address "' `� 1 Cs LOTS <br /> Inspection Date <br /> Time In Time Out <br /> Business Rep TitleO AM n O AM <br /> C -_ • O <br /> O t�Jl er' ® PM �/ ® PM <br /> Operational Status Tire Type Business Rote Storage Type <br /> Tire Count (Whole/PTE) (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> 9 0 Active 0 Passenger 0 Generator 0 Outdoor <br /> O 0 Closed 0 Altered <br /> GPS Latitude 0 Hauler 0 Indobr' <br /> D 0 Inactive 6 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 e 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 <br /> Part B - Inspection of Waste Tire Dealer, Generator, Hauler and End-Use Facility ENFORCEMENT STATUS <br /> V A I HAULING AND MANIFEST REQUIREMENTS <br /> 0 Notice Of Violation Q 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 /> PRC§42956-Registration/Decal in Vehicle <br /> 0 0 14 CCR§18459-Responsible Entities Complying with Manifesting Requirements Date <br /> 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 EX7) N <br /> 0 0 14 CCR§18459.3-Retention of Comprehensive Trip Logs for 3 years N <br /> 0 <br /> 0 0 14 CCR§18460.2-Manifest System Requirements for Registered Waste Tire Haulers 0 Referred/CalRecycle Enforcement <br /> 0 0 14 CCR§18461 -Manifest System Requirements for Waste Tire End-Use Facilities u, <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 /> (9�AWes n <br /> Inspection Form Included: 0 <br /> Comments Included: ® CJ�sgsG� _ <br /> usiness Re Signature Phone Number Insp or's Sig`nature Phone Number <br /> 62081 <br /> INSTRUCTIONS ON BACK [Correct.* Incorrect: EXA L 1 2 3 <br /> ■ White Copy:CalRecycle Yellow Copy:Operator Pink Co y:L © ■ <br />