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Waste Tire Stey & Inspection Report tlspection Report Number <br /> CalRec cle State of California _ <br /> Y CalRecycle 181(Rev.10/10) Survey Form - Page 1 I1 1242494 <br /> Dept.of Resources Recycling and Recovery(CalRecycle) <br /> 'art A-Survey BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- I 1 � n g � � _ O � Inspection Type(Fill one) <br /> a <br /> Site Suffix: �Q ® Routine Q Re-inspection Q Referral Q Observation <br /> Localr-- If Referral,choose referral type(Fill one) <br /> Identifier: �OLo J (X jLL1 rN �t.1{1 Q CHP Q CalRecycle Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name Inspected By Inspector <br /> Q0115Q— CCt4'C"CL 3 9 - C� <br /> Physical Address 1 C_ '0 <br /> t / l (0 C �533D Inspection Date 1 1 <br /> Time In Time Out <br /> Business Rep Title 16 AM IN AM <br /> J S 0 PM 2 O PM <br /> _T,0,t:� OSunw o� �-;�,5 rn�s. <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 /> ® Active 0 Passenger 0 Generator Q Outdoor <br /> O Q Closed Q Altered � <br /> GPS Latitude Q Hauler Q Indd'or)i <br /> O Q Inactive ® Truck <br /> Longitude - Q Planned 0 OTR O End-Use O Container <br /> Business Type(Fill all that apply) vorh it <br /> Q New Tire Dealer Q Auto Repair B 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 lb 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 /> O O <br /> PRC§42951 -Waste Tire Hauler Registration and Transport of Tires <br /> O O PRC§42953-Contracts with Registered Waste Tire Haulers. Compliance Deadline <br /> PRC§42956-Registration/Decal in Vehicle <br /> O O 14 CCR§18459-Responsible Entities Complying with Manifesting Requirements Date M / m / m <br /> O O 14 CCR§18459.1 -Tire Program ID Number from CalRecycle N <br /> O O 14 CCR§18459.2.1 -Submittal of Comprehensive Trip Logs within 90 days (Required for NOV or EX1) N <br /> O O 14 CCR§18459.3-Retention of Comprehensive Trip Logs for 3 years u) <br /> 0 <br /> O O 14 CCR§18460.2-Manifest System Requirements for Registered Waste Tire Haulers Q Referred/CalRecycle Enforcement <br /> Lu <br /> O 0 14 CCR§18461 -Manifest System Requirements for Waste Tire End-Use Facilities <br /> O Q 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators In Compliance-No Violations o <br /> O O Other:§ 11 1 1 1 1 <br /> Comments <br /> A! ��e�,nok ilav, <br /> cte <br /> A i ale-us <br /> Inspection Form Included: '^ p <br /> Comments Included-" �j/� �'" v' <br /> sl s ignature Phone Number Ins a tor's Signature Phone Number <br /> INSTRUCTIONS ON BACK Correct: Incorrect: E X A M P L 1 2 3 62081 <br /> White Copy:CalRecycle Yellow Copy:Operator Pink Cop L <br />