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E 2 Waste Tire S ey & Inspection Repo�spection Report Number <br /> CalRecycle state of California <br /> Y CalRecycle 181(Rev.10/10) Survey Form - Page 1 I1 - 1196531 <br /> Dept.of Resources Recycling and Recovery(CalRecycle) <br /> Part A-Survey - BLUE_OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- 1 _7 " �} e _ a 1 Inspection Type(Fill one) <br /> Site Suffix: _1 -I > I* Routine Q Re-inspection Q Referral Q Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier: Sav,' r� C3 0 CHP Q CalRecycle Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name 1 r Inspected By Inspector <br /> Physical Ad ess <br /> ` 7 g �® J�-eo.� �r�c��01- <br /> CI,�,53 Inspection Date 9 <br /> Time In Time Out <br /> Business Rep Title ` O AM CO AM <br /> PM �PM <br /> Operational Status Tire Type Business Role Storage Type <br /> Tire Count(Whole/PTE) (FII one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> Active 4P Passenger Generator 0 Outdoor <br /> O Q Closed Q Altered <br /> GPS Latitude Q Hauler Q Indoor <br /> 0 Q Inactive 0 Truck <br /> Longitude - Q Planned Q OTR 0 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 Retreradcr 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 (�����\�� C�1�C2 <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. I Compliance Deadline <br /> PRC§42956-Registration/Decal in Vehicle <br /> Q Q 14 CCR§18459-Responsible Entities Complying with Manifesting Requirements I Date m / m / m <br /> 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 E)CT) N <br /> Q Q 14 CCR§18459.3-Retention of Comprehensive Trip Logs for 3 years I o <br /> Q Q 14 CCR§18460.2-Manifest System Requirements for Registered Waste Tire Haulers Q Referred/CalRecycle Enforcement <br /> Uj <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 /> o V•c�.c���i�a�S BC �cca.� � �Q�r� , <br /> Inspection Form Included: Q 7-5.00d� - <br /> Comments Included: CIA <br /> Business Rep's Signature Phone Number Inspect is Signature Phone Number <br /> INSTRUCTIONS ON BACK Correct:* Incorrect: *�q IEIXIAIMIPILIEI 1112 3 62081 <br /> ■ White Copy:CalRecycle Yellow Copy:Operator Pink Copy:LFA ® 0 <br />