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Waste Tire SWey & inspection Repor Inspection Report Number <br /> CalRecycle State of California — <br /> Y CalRecycle 181(Rev.10/10) Survey Form Page 1 Il 1186136 <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- Inspection� � 7 Inspection Type(Fill one) <br /> Site Suffix: �j ! J ®Routine Q Re-inspection Q Referral Q Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier: Q CHP Q CalRecycle Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name Inspected By Inspector <br /> l J)� /� 1 r✓`� /, V <br /> l� <br /> Physical Address 0 0 <br /> Inspection Date /7 �l / �-L -z- / <br /> Time In l/ ( Time Out <br /> Business Rep Title I f '® AM AM <br /> �+ S QPM ' 0 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 /> 9 ' 0 Active Q Passenger 0 Generator Q Outdoor <br /> O Q Closed Q Altered <br /> GPS Latitude Q Hauler Q Indoor <br /> O Q Inactive Q Truck <br /> Longitude - Q Planned ® 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 Q Other <br /> Part B - Inspection of Waste Tire Dealer, Generator, Hauler and End-Use Facility ENFORCEMENT STATUS <br /> TVHACU,LFING AND MANIFEST REQUIREMENTS Q Notice Of Violation Q Extension <br /> 42951 -Waste Tire Hauler Registration and Transport of Tires <br /> 42953-Contracts with Registered Waste Tire Haulers. j Compliance Deadline <br /> 42956-Registration/Decal in Vehicle <br /> §18459-Responsible Entities Complying with Manifesting Requirements DateQQ14 CR§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 EXE N <br /> Q Q 14 CCR§18459.3-Retention of Comprehensive Trip Logs for 3 years c <br /> Q Q 14 CCR§18460.2-Manifest System Requirements for Registered Waste Tire Haulers Q Referred/CalRecycle Enforcement <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:§ - __-._-- I <br /> Comments ) GL <br /> e,-s,-L,4n, V�Jlellv 1_,T-4 6 4 tylu L'y-, lvn <br /> Inspection Form Included: coq -("y /PjlJP[ <br /> Comments Included: <br /> Business ep's Signature Phone Number - Inspector's Signature Phone Number <br /> INSTRUCTIONS ON CK Correct: <br /> Incorrect: �� E X A M P L E 1 2 3 62081 <br /> White Copy:CalRecycle Yellow Copy:Operator Pink Copy:LEA <br />