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Waste Tire Survey & Inspection Report inspection Report Number ■ <br /> Cal Rec cle State of California <br /> Y CalRecycle 181(Rev.10/10) Survey Form - Page 1 11 - 1196357 <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� � � — © � Inspection Type(Fill one) <br /> � � <br /> Site Suffix: I• Routine 0 Re-inspection 0 Referral 0 Observation <br /> Local I If Referral,choose referral type(Fill one) <br /> Identifier: n JO" 0 CHP 0 CalRecycle 0 Complaint 0 Educational Visit 0 Other <br /> Business or Facility Name Inspected By Inspector <br /> Q PM 4c-n <br /> Physical Address <br /> t 0 s c1,� �. -J ;a 1 PCt <br /> Inspection Date � / V <br /> Time In Time Out 1 I <br /> Business Rep Title O AM I O AM <br /> I �OPCwp,'c/\ S U 0 PM l O O PM <br /> 1�no, �Q.va Ice, ,rc�u^� er <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 ff Generator 0 Outdoor <br /> 0 0 Closed 0 Altered / <br /> GPS Latitude 0 Hauler 0 Indoor <br /> O 0 Inactive ® Truck <br /> Longitude — 0 Planned 0 OTR 0 End-Use 0 Container <br /> Business Type(Fill all that apply) <br /> 0 New Tire Dealer 0 Auto Repair *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 1 <br /> 0 Service Station 0 Hauler 0 Agriculture 0 Shredder ® Other Flouv n _ +J'r <br /> Part B - Inspection of Waste Tire Dealer, Generator, Hauler and End-Use Facility ENFORCEMENT STATUS <br /> V A HAULING AND MANIFEST REQUIREMENTS <br /> 0 Notice Of Violation 0 Extension <br /> 0 0 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 3 <br /> 0 0 14 CCR§18459.2.1 -Submittal of Comprehensive Trip Logs within 90 days (Required 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 A In Compliance-No Violations o <br /> 0 1 0 Other:§ <br /> Comments4A_�l N1, S�WtA 1 r , n� r V^ Dne, ors 'S 4 N <br /> N 0 o I kk 10s 4 J CA.l 0 US b4- C on f s-ra <br /> Inspection Form Included: s�o� t/ ��tl�f A <br /> Comments Include ��7 Z(—— �v _` <br /> Business ature Phone Number Inspec is Signature Phone Number <br /> 11 62081 <br /> INSTRUCTIONS ON BACK Correct: Incorrect: 'Z\ g EXAM P L E 1 2 3 <br /> ■ White Copy:CalRecycle Yellow Copy:Operator Pink Cop :L © ■ <br />