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Waste Tire SU, vey & Mspection Report inspection Report Number <br /> CalRecycle State of California <br /> Y CalRecycle 181(Rev.10110) Survey Form - Page I. I1 1242107 <br /> Dept.of Resources Recycling and Recovery(CalRecycle) <br /> Part A- Survey <br /> BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- Z 2 �? Inspection Type(Fill one) <br /> Site Suffix: 1 �1 G 7 3 ® Routine Q Re-inspection Q Referral Q Observation <br /> Local `` If Referral,choose referral type(Fill one) <br /> Identifier: Sf�V1 JfY� C� �� Q CHP Q CalRecycle Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name Inspected By Inspector <br /> Physical Addr ss c_ <br /> Inspection Date s? <br /> Time In Time Out <br /> Business Rep Titleff ^� ®AM ® AM <br /> r` J <br /> ;A( fCMGb✓ICG� I �1. O PM ( U J, O PM <br /> r_ Operational Status Tire Type Business Role .Storage Type <br /> Tire Count (VI/hole/PTE) © (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> ' ® Active ® Passenger ® Generator ® Outdoor <br /> O Q Closed Q Altered <br /> GPS Latitude Q Hauler ® Indoor <br /> 0 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 ® 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 Other1�� <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 N <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 /> 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 /> - - z <br /> Comments <br /> Inspection Form Included: Q <br /> Comments Included: <br /> usiness Rep's Sign re Phone Number I p t r' i ture Phone'Number <br /> 62081 <br /> INSTRUCTIONS ON BACK I Correct:* Incorrect: E I x�A M L I E 1 1 2 3 <br /> ■ White Copy:CalRecycle Yellow Copy:Operator Pink Copy:LEA ® ■ <br />