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Waste Tire Sur vey & Inspection Report Inspection Report Number <br /> CalRecycle State of California <br /> Y CalRecycle 181(Rev.10/10) Survey Form - Page 1 1 - 1177729 <br /> Dept.of Resources Recycling and Recovery(CalRecycle) <br /> Part A-Survey BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- / Q 1 Inspection Type(Fill one) <br /> Site Suffix: 0 Routine Q Re-inspection Q Referral Q Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier: svv �� l�`71 Co J Q CHP Q CalRecycle Q Complaint Q Educational Visit Q Other <br /> BusinessorFacility Name Inspected By Inspector <br /> ! _ � d 6 <br /> Physical Address `� MATTU <br /> Inspection Date <br /> Time In Time Out <br /> Business Rep Title O AM �+ O AM <br /> 3 -5 ® PM L1 *PM <br /> i - 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 Q Passenger 1§ Generator ® Outdoor <br /> O Q Closed Q Altered <br /> GPS Latitude Q Hauler Q Indoor <br /> o Q Inactive ®Truck <br /> Longitude - Q Planned Q OTR Q End-Use • Container <br /> Business Type(Fill all that apply) <br /> Q New Tire Dealer Q Auto Repair 4&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 Q Other <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 /> QQ 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 4 <br /> Q 0 14 CCR§18459.2.1 -Submittal of Comprehensive Trip Logs within 90 days (Required for NOV or EXE <br /> Q Q 14 CCR§18459.3-Retention of Comprehensive Trip Logs for 3 years o <br /> Q Q 14 CCR§18460.2-Manifest System Requirements for Registered Waste Tire Haulers Q Referred/CalRecycle Enforcement <br /> Lu <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 o <br /> Q Q Other:§ f <br /> Comments �Zqy - k-A)a--> 2cTZlt�V1 <br /> r <br /> m d OAS Off NrM5 0 G✓AW_r! <br /> Inspection Form Included: Q "Signature <br /> Comments Included: —usiness Rep's Signature Phone Number Inspe ore's Phone Number <br /> INSTRUCTIONS ON BACK Correct:* incorrect: E X A M P L E 1 2 3 62081 <br /> ■ White Copy:CalRecycle Yellow Copy:Operator Pink Copy:LEA ® 0 <br />