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Waste Tire Su, sjey & Inspection Report Inspection Report Number ■ <br /> CalRecycle CalRecyclel1fornia 181(Rev.10/10) Survey Form - Page 1 I1 — 1196597 <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 1 Inspection Type(Fill one) <br /> Site Suffix: b I* Routine Q Re-inspection Q Referral Q Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier: 'y�Q Ver COV,n Q CHP Q CalRecycle Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name `�"�1 Inspected By Inspector <br /> .� M. �9�%e w)Q`^ `I - 1 d 1 <br /> Physical Address MA T T v <br /> S Inspection Date 1 Z / -7 ` 3 <br /> Time In Time Out <br /> Business + <br /> Rep � Title 1 b 2 AM <br /> 0 PM I Z Q 0 PM <br /> 4 Go=kv '9 40 <br /> �.Yl 7�r.6 �O�Yv�Qh 1 J <br /> U. Operational Status Tire Type Business Role Storage Type <br /> Tire Count (Whole/PTE) n (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> 9 Active Q Passenger 0 Generator 0 Outdoor <br /> O Q Closed Q Altered <br /> GPS Latitude Q Hauler Q Indoor <br /> O Q Inactive Q Truck <br /> Longitude - Q Planned 0 OTR Q End-Use 40 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 0 Other V31V%e s-\�'s1'¢e�� <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 <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 EX7) n <br /> Q O 14 CCR§18459.3-Retention of Comprehensive Trip Logs for 3 years <br /> 0 <br /> Q Q 14 CCR§18460.2-Manifest System Requirements for Registered Waste Tire Haulers Q Referred/CalRecycle Enforcement <br /> Lu <br /> W <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 /> Commentsr e- �hSPeL'ty <br /> r c,c ceAS C,r>w <br /> Inspection Form Included: QAlnpe <br /> Comments Included: � Business Rep's Signature Phone Number or's Signature Phone Number <br /> INSTRUCTIONS ON BACK Correct:41 Incorrect: M � q� E X A M P L E 1 ) 3 62081 <br /> ■ White Copy:CalRecycle Yellow Copy:Operator Pink Copy:LEA © ■ <br />