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Waste Tire Survey & Inspection Rep rt Inspection Report Number <br /> CalRec cle State of California — <br /> Y CalRecycle 181(Rev.10/10) I1 12 5 5 7 5 2 <br /> Dept.of Resources Recycling and Recovery(CalRecycle) Survey Form - Page 1 <br /> )art A- Survey BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- I � � � Q' Cif � - � ` Inspection Type(Fill one) <br /> Site Suffix: D ( I 01 Routine Q Re-inspection Q Referral Q Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier: 3=q -)k 0 CHP OCalRecYcle 0 Complaint OEducational Visit OOther <br /> Business or Facility Name Inspected By Inspector <br /> �_Oa 0�p rVt`cq c _ ( ' <br /> Physical Address J / C� J �)PCf�/� �Oy <br /> // 40 I s. t�,r to rt /god <br /> lInspection Date <br /> C!� �-3(0 Time In Time Out`v C <br /> Business Rep Title I r E ®AM ® AM <br /> `-� QPM 1+rd <br /> I ? QPM <br /> Operatiynal Status Tire Type Business Role Storage Type <br /> Tire Count(Whole/PTE) <br /> (Fill one only). (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> `'� <br /> ®Active Q Passenger Is Generator 40 Outdoor <br /> Q Closed Q Altered <br /> GPS Latitude Q Hauler Q Indoor <br /> 0 Q Inactive • Truck <br /> Longitude - Q Planned Q 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 ® Other rk1[1b()(2 <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 /> Q Q <br /> PRC§42951 -Waste Tire Hauler Registration and Transport of Tires <br /> Q Q PRC§42953-Contracts with Registered Waste Tire Haulers. Compliance Deadline <br /> PRC§42956-Registration/Decal in Vehicle <br /> Q O 14 CCR§18459-Responsible Entities Complying with Manifesting Requirements Date m / m / m <br /> 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 EX7) N <br /> a <br /> Q • 14 CCR§18459.3-Retention of Comprehensive Trip Logs for 3 years <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 <br /> Q Q Other:§ l <br /> Comments Tbk&4LZ' �:Iwe tuo 1 " �ovi di%_L <br /> f � <br /> 1,) up �' ` <br /> 2.s�-- c ci'fix" eo i-a <br /> Inspection Form Included: Q &L <br /> Comments Included: 0 - — <br /> Business p's Signature Phone NuLo o <br /> mber Inspect 's Signature Phone Number <br /> INSTRUCTIONS ON BACK Correct: Incorrect: )< � V EXAM PILE 1 2 3 162081 <br /> White Copy:CalRecycle Yellow Copy:Operator Pink Copy:LEA �� <br />