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Waste Tire Survey & Inspection Report Inspection Report Number <br /> cle State of California <br /> CalRecycle Y CalRecycle 181(Rev.10/10) Survey Form o Gage 1 11 - 1244935 <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 I � � , ^ O 1 Inspection Type(Fill one) <br /> Site Suffix: v� v $ 1J 0 Routine Q Re-inspection Q Referral Q Observation <br /> Local e If Referral,choose referral type(Fill one) <br /> Identifier: JW1 Z()tt()i (ni"l (()_LlQ CHP Q CalRecycleQ Complaint Q Educational Visit Q Other <br /> Business or Facility Name b Inspected By Inspector <br /> Physical Address <br /> X35 b <br /> Inspection Date ' a- <br /> Time In Time Out <br /> Business Rep Title O AM O AM <br /> S <br /> ® PM � � J V 0 PM <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 Q Pwie)lnger Q Generator Q Outdoor <br /> o h r4 N <br /> I& Closed Q Altered- 1h } <br /> GPS Latitude Q Hauler Q Indoor <br /> o Q Inactive Q Truck <br /> Longitude - Q Planned Q 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 Q Other N Aq <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 0 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 /> QO 14 CCR§18459-Responsible Entities Complying with Manifesting Requirements Date m / FTI / m <br /> Q O 14 CCR§18459.1 -Tire Program ID Number from CalRecycle <br /> Q O 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 Q 14 CCR§18460.2-Manifest System Requirements for Registered Waste Tire Haulers O Referred/CalRecycle Enforcement <br /> Q O 14 CCR§18461 -Manifest System Requirements for Waste Tire End-Use Facilities u, <br /> Q Q 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators <br /> in Compliance-No Violations o <br /> Q Q Other:§ <br /> Comments 154 ��f� Al 11 TLA n ohdN <br /> u eS QnS) Ic= <br /> 1. 7PN.)M u,=,5 0�&idA 76f if, (00 ).m9 � <br /> a <br /> Inspection Form Included: Q <br /> Comments Included: Q �l <br /> k <br /> iness Rep's Signature Phone Number Ins or's Signature Phone Number <br /> INSTRUCTIONS ON BACK Correct:* Incorrect: --]IEIXIAIMIPILIEI 1112 3 62081 <br /> ■ White Copy:CalRecycle Yellow Copy:Operator Pink Copy:LEA ® ■ <br />