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Waste Tire Sui vey & Inspection Report Inspection Report Number <br /> State of California <br /> CalRecycle <br /> CalRecycle 181(Rev.10/10) Survey Form - Page 1 I1 - 1177779 <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: 1 6 97 6 11 ® Routine Q Re-inspection Q Referral Q Observation <br /> Locale� n �� If Referral,choose referral type(Fill one) <br /> Identifier: C7Lt c�/1/�'v Q CHP Q CalRecycle Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name Inspected By Inspector <br /> Physil <br /> caddress �/1 <br /> aiC) L E, r Icy.✓ <br /> Inspection Date <br /> Time In Time Out <br /> Business Rep Title1 ' ® AM ® AM <br /> I I _ _ l U 0 P ` 0 P <br /> Operational Status Tire Type Business Role Storage Type <br /> Tire Count (Whole/PTE) S (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> 4P Active ® Passenger ® Generator ® Outdoor <br /> O Q Closed Q Altered <br /> GPS Latitude Q Hauler Q Indoor <br /> 0 Q Inactive Q Truck <br /> Longitude - Q Planned Q OTR Q End-Use Q Container <br /> Business Type(Fill all that apply) <br /> ® New Tire Dealer ®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 - - Q Notice Of Violation Q Extension <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 Q 14 CCR§18459-Responsible Entities Complying with Manifesting Requirements Date <br /> M / M / mC.)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 c? <br /> Q 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 /> Q Q 14 CCR§18461 -Manifest System Requirements for Waste Tire End-Use Facilities __ W <br /> Q Q 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators ®In Compliance-No Violations o <br /> Q Q Other:§ <br /> Comments <br /> Inspection Form Included: Q /� C <br /> Comments Included: <br /> Business Rep's Signature Phone Number I p tor's P(gr)dtuW P(gr)toPhone Number <br /> �-,( 62081 <br /> INSTRUCTIONS ON BACK Correct: Incorrect: X L`�J E A 1 2 3 <br /> ® White Copy:CalRecycle Yellow Copy:Operator Pink o <br />