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Waste Tire Survey <br /> & Inspection Repo rtInspection Report Number <br /> State of CaliforniaCalRecycle CalRecycle 181(Rev. <br /> Survey Form - 1 - <br /> Dept.of Resources Recycling and Recovery(CalRecycle) Page 1 <br /> BLUE OR BLACK INK PEN <br /> Part A-Survey <br /> Business Profile Inspection Details <br /> TPID- I Inspection Type(Fill one) <br /> Site Suffix: I 6 5 7 S O z 0 1 0 Routine Q Re-inspection Q Referral Q Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier: �'p�4v��n COyr Q CHP Q CalRecycle Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name r <br /> Inspected By Inspector <br /> Physical <br /> DAddress sPe- Fc-a2 �ooc�-s 3 9 <br /> Physical <br /> 166$ <br /> tt Inspection Date O 7 Z 1 y <br /> SKko,r� �� gsZoS Time In Time Out <br /> Business Rep Title &AM 1 1 i AM <br /> 1 d QPM Y ` QPM <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 /> 0 Active Q Passenger 0 Generator Q Outdoor <br /> D Q Closed Q Altered MIA <br /> Latitude Q Hauler Q Indoor <br /> O Inactive Truck <br /> Longitude — Q Planned 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 0 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 0 OtherCutT <br /> Part B - Inspection of Waste Tire Dealer, Generator, Hauler and End-Use Facility ENFORCEMENT STATUS <br /> V I 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 /> Q Q PRC§42956-Registration/Decal in Vehicle <br /> Q O 14 CCR§18459-Responsible Entities Complying with Manifesting Requirements Date M / m / m <br /> Q Q 14 CCR§18459.1 -Tire Program ID Number from CalRecycle j <br /> Q Q 14 CCR§18459.2.1 -Submittal of Comprehensive Trip Logs within 90 days (Required for NOV or EXE N <br /> Q O 14 CCR§18459.3-Retention of Comprehensive Trip Logs for 3 years <br /> Q O 14 CCR§18460.2-Manifest System Requirements for Registered Waste Tire Haulers Q Referred/CalRecycle Enforcement <br /> Q O 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 _� ��, \,Oh Azre_-Q)4 MA-AS &0k coa Availz <br /> s Cov�ecr� <br /> Inspection Form Included: Q2 <br /> Comments Included: l�S � 209—q M l <br /> B Hess Rep's Si atur Phone Number Inspector's Signature Phone Number <br /> INSTRUCTIONS ON BACK Correct: Incorrect: X � EXAM P L E 1 2 3 62081 <br /> White Copy:CalRecycle Yellow Copy:Operator Pink Copy:LEA <br />