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2 Waste Tire trey & Inspection RepoInspection Report Number ■ <br /> CalRecycle State of California % <br /> CalRecycle 181(Rev.10110) Survey Form - Page 1 I1 - 1176612 <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: [ 2 ,�j C) <br /> ® Routine Q Re-inspection Q Referral Q Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier: �G1v1 w Q CHP Q CalRecycle Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name j V Inspected By Inspector <br /> S. ?C . Lo cA ;3 <br /> Physical Address <br /> Inspection Date <br /> Time In Time Out <br /> Business Rep Title ® AM ® AM <br /> 0P ! O o 0P <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 /> Q Active Q Passenger Q Generator Q Outdoor <br /> O <br /> GPS Latitude ® Closed Q Altered Q Hauler Q Indoor <br /> p Q Inactive Q Truck <br /> Longitude - Q Planned Q OTR Q End-Use Q Container <br /> Business Type(Fill all that apply) <br /> Q New Tire Dealer ® 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 .y . <br /> Part B - Inspection of Waste Tire Dealer, Generator, Hauler and End-Use Facility ENFORCEMENT STATUS <br /> VTA <br /> Q Q PRC§HAULING AND51 - aste MANITirF ESTeRRQUREM egistrationREQUIREMENTS <br /> Sansport of Tires Q Notice Of Violation Q Extension <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 pate 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 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 /> f <br /> Q Q 14 CCR§18461 -Manifest System Requirements for Waste Tire End-Use Facilities <br /> is W <br /> r <br /> Q Q 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators <br /> in Compliance-No Violations g o <br /> Q Q Other:§ H� f k <br /> Comments u <br /> - �.•yc�-�v�r, a Y}���1�� `t'L�t r c�L.s.� /'i Ancil _-11�t� �D l(clt.0 <br /> tnJ_ius _1CK01CG <br /> Inspection Form Included: Q <br /> Comments Included: -'201) 46 a-0�2 3 <br /> Business Rep's Signature Phone Number spector's Signature Phone Number <br /> INSTRUCTIONS ON BACK LCorrect:0 Incorrect I E I X I A IMI 1112 31 62081 <br /> White Copy:CalRecycle Yellow Copy:Operator Pink Copy: EA �� <br />