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It <br /> 02 Waste Tire Su, ,✓ey & Inspection Report inspection Report Number <br /> Cal Rec cle State of California <br /> Y CalRecycle 181(Rev.10/10) Survey Form - Page 1 I1 -1176793 <br /> Dept.of Resources Recycling and Recovery(CalRecycle) <br /> Part A-Survey BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- Inspection Type(Fill one) <br /> Site Suffix: I < I y 3 Ll 0 l ig Routine Q Re-inspection Q Referral Q Observation <br /> LocalIf Referral,choose referral type(Fill one) <br /> Identifier: SC 0,eb;.A_y-\. Co//1 ''Ll Q CHP Q CalRecycle Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name Inspected By Inspector <br /> Le �c:tic,�c�1c� -f� 6,65 _ <br /> Physical Address � 1 a pal -im��, /�-►2�rt1 (�V(�� <br /> 5 6� <br /> co , G-T"Y"t �_"Vut Iii<� <br /> Inspection Date ® l 1 <br /> fo,CAI CA C'5g()4 .S l <br /> Time In Time Out <br /> Business Rep Title O AM O AM <br /> c2- ' 0 ® PM Lf *PM <br /> Operational Status Tire Type Business Role Storage Type <br /> - <br /> Tire Count(Whole/PTE) (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> f ' 0 Active ® Passenger ® Generator Q Outdoor <br /> O Q Closed ® Altered <br /> GPS Latitude Q Hauler Indoor <br /> O Q Inactive 0 Truck <br /> Longitude - Q Planned ® OTR Q End-Use Q Container <br /> Business Type(Fill all that apply) <br /> 0 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 Q Other <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 /> Q Q 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 EXn N <br /> Q Q 14 CCR§18459.3-Retention of Comprehensive Trip Logs for 3 years <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 <br /> In Compliance-No Violations o <br /> Q Q Other:§ <br /> Comments <br /> Inspection Form Included: 0 / <br /> Comments Included: (all - <br /> Business Rep's Sign re Phone Number I e to S ature Phone Number <br /> 62081 <br /> INSTRUCTIONS ON BACK Correct:I, Incorrect: E X A M JE1,111213 <br /> 0 White Copy:CalRecycle Yellow Copy:Operator Pink Co y:LE © ■ <br />