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Inspection Report Number <br /> � Waste Tire Survey & Inspection Report p p <br /> CalRecycle State of California — <br /> Y CalRecycle 181(Rev.10/10) Survey Form - Page 1- 11 1229995 <br /> Dept.of Resources Recycling and Recovery(CalRecycle) <br /> Part A-Survey BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- O Inspection Type(Fill one) <br /> Site Suffix: 1 7 - 5 S , Routine Q Re-inspection Q Referral Q Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier: 50.r To"V�Y-N (�6V Q CHP Q CalRecycle Q Complaint Q Educational Visit Q Other <br /> Business or Facility Namecel Inspected By Inspector <br /> ,x r Co Ev�cce ,, �nc� e 2 C, - 1 1 <br /> Physical Address Yr l� d I I C) l T <br /> Inspection Date o 3 _S <br /> L 1 S�o Lv�V. C1 _ 9SZ IS v <br /> Time In Time Out <br /> Business Rep Title Yr.vti AM O AM <br /> 2 e - 4&PM O 40 PM <br /> I ov��2 c }occ,�C <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 /> Q Active 40 Passenger ® Generator Q /Ouut oor <br /> O <br /> GPS Latitude 0 Closed 40 Altered Q Hauler Q Indoor <br /> O Q Inactive ®Truck <br /> Longitude - Q Planned O 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 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 <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 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 /> PRC§42956-Registration/Decal in Vehicle <br /> QQ 14 CCR§18459-Responsible Entities Complying with Manifesting Requirements Date <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 EXE N <br /> a <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 /> Uj <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:§ z <br /> Comments <br /> CL � <br /> Inspection Form Included: Q <br /> Comments Included: Q G <br /> Business Rep's Signatu Phone Number 'Inspec is Signature Phone Number <br /> INSTRUCTIONS ON BACK Correct:0 Incorrect: EXAMPLE 11]2 3 62081 <br /> ■ White Copy:CalRecycle Yellow Copy:Operator Pink Copy:LEA <br />