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Waste Tire Survey & Inspection Repon Inspection Report Number <br /> cle State of California <br /> CalRecycle Y CalRecycle 181(Rev.10/10) Survey Form - Page 1 I1 - 1210281 <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: 1 y 3 3 01 ® Routine 0 Re-inspection 0 Referral 0 Observation <br /> Local lReferral,choose referral e(Fillone) <br /> Identifier: If <br /> CalRecycleOComplaint 0 Educational Visit <br /> Other <br /> Business or Facility Name Inspected By Inspector <br /> Physical Address- --s <br /> Inspection Date <br /> L C6; CA q5a`40 <br /> Time In Time Out <br /> Busiiness ep Title AM PM <br /> . j >� ® PM ..�_ 40 <br /> - -- Operational Status Tire Type Business Role Storage Type <br /> Tire Count (Whole/PTE) (Fill one only) (FII all that apply) (Fill all that apply) (Fill all that apply) <br /> 4 <br /> ' ' 0 Active 0 Passenger Generator 0 Outdoor <br /> O 0 Closed 0 Altered <br /> GPS Latitude 0 Hauler 0 Indoor <br /> O Q Inactive ItTruck <br /> Longitude - 0 Planned ® OTR 0 End-Use 0 Container <br /> Business Type(Fill all that apply) <br /> 0 New Tire Dealer 0 Auto Repair 0 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 Lwnda <br /> Part B - Inspection of Waste Tire Dealer, Generator, Hauler and End-Use Facility ENFORCEMENT STATUS <br /> A HAULING AND MANIFEST REQUIREMENTS <br /> V <br /> V0 0 Notice Of Violation 0 Extension <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 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 (Require for NOV or EXE N <br /> 0 0 14 CCR§18459.3-Retention of Comprehensive Trip Logs for 3 years o <br /> 0 0 14 CCR§18460.2-Manifest System Requirements for Registered Waste Tire Haulers 0 Referred/CalRecycle Enforcement <br /> 2 <br /> 0 0 14 CCR§18461 -Manifest System Requirements for Waste Tire End-Use Facilities W <br /> 0 0 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators <br /> is in Compliance No Violations o <br /> 0 0 Other:§ <br /> Comments <br /> V <br /> Inspection Form Included: 0 <br /> Comments Included: ® - -� <br /> Business Rep's Si nature o umber fn0e46r'srSIgKaAre Phone Number <br /> INSTRUCTIONS ON BACK I Correct: Incorrect: g E I X�A'j 1112131 <br /> 62081 <br /> White Copy:CalRecycle Yellow Copy:Operator Pink Cop L <br />