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02 Waste Tire Su.,, ey & Inspection Report nspection Report Number <br /> CalRecycle State of California I 1 - 117 7 5 41 <br /> CalRecycle 181(Rev.10/10) Survey Form - Page 1 <br /> Dept,of Resources Recycling and Recovery(CalRecycle) <br /> Part A-Surve BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- , � ry _ O j Inspection Type(Fill one) <br /> Site Suffix: �j ® Routine Q Re-inspection Q Referral Q Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier: �p0.Q .� �-) Q CHP Q CalRecycle Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name 1 \ Inspected By Inspector <br /> I-ow �c^lG2 ��uJ vS `f�S C� l ✓ "\ <br /> Physical Address <br /> ,d C& �V�CJ`u Ci�('\CA Vt v\t- <br /> Inspection Date z / 1 / 2 <br /> CA 015337 <br /> Time In Time Out <br /> Business Rep Title O AM 0 O AM <br /> 2 � o � 0 PM � � d 0 PM <br /> Operational Status Tire Type Business Role Storage Type <br /> 5 (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> Tire Count(V1lhole/� �j <br /> � ' 0 Active 40 Passenger I* Generator &Outdoor <br /> Q Closed Q Altered <br /> GPS 'Latitude Q Hauler Q Indoor <br /> O Q Inactive Q Truck <br /> Longitude — Q Planned Q OTR Q End-Use Q Container <br /> Business Type(Fill all that apply) <br /> _l New Tire Dealer Q Auto Repair Q Trucking Fleet Q Government Q Retreader Q Dismantler Q Tire Derived Fuel <br /> 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 Q PRC§42951 -Waste Tire Hauler Registration and Transport of Tires Notice Of Violation Q Extension <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 <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 EXT) N <br /> a <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 /> W <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 Q In Compliance-No Violations o <br /> Q Q Other:§ <br /> z <br /> Comments � w � .� � �e X114- A)ns)r— ` <br /> Inspection Form Included: Q44tL2bq—L%S-329 <br /> Comments Included: O� <br /> s Re 's Sig ature Phone N tuber Inspe tor's Signature Phone Number <br /> 62081 <br /> INSTRUCTIONS ON BACK4orrect:0Incorrect: X V EXAMPLE 1111 1 2 3 <br /> ■ White Copy:CalRecycle Yellow Copy:Operator Pink Copy:LEA © ■ <br />