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Waste Tire Survey & Inspection Report Inspection Report Number <br /> cle State of California <br /> CalRecycle CalRecycle 181(Rev.10/10) Survey Form ® gage 1 I1 1210522 <br /> Dept.of Resources Recycling and Recovery(CalRecycle) <br /> F' A-Survey <br /> BLUE OR BLACK INK PEN <br /> less Profile Inspection Details <br /> TVID- Inspection Type(Fill one) <br /> Site Suffix: 4j � L Q Referral Q Observation p <br /> Local -, r_, If Referral,choose referral type(Fill one) <br /> Identifier: ��h. ` E Q CHP Q CalRecycle Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name Inspected By Inspector <br /> J _ <br /> Physical Address l Z Cj <br /> Ill. <br /> Inspection Date 0 <br /> s�d� Time In 1 Time Out <br /> Business Rep nnTitle 0 AM / ] AM <br /> Ivv t / 0 ' � U O FM l G C.l � O PM <br /> Operational Status Tire Type Business Role Storage Type <br /> Tire Count (Whole/PTE) (Fill one only) (FII all that apply) (Fill all that apply) (Fill all that apply) <br /> Q Active ®Passenger ® Generator Q Outdoor <br /> O 0 Closed Q Altered <br /> GpS Latitude Q Hauler Q'Indoor <br /> O Q Inactive Q Truck <br /> Longitude - Q Planned Q OTR O End-Use Q Container <br /> Business Type(Fill all that apply) <br /> Jew Tire Dealer Q Auto Repair Q Trucking Fleet Q Government Q Retreader Q Dismantler Q Tire Derived Fuel <br /> Used Tire Dealer Q Auto Body Q Car Dealer Q Collection Q Crumb Rubber <br /> kc:_Ewtp R7 %�,,✓sem � <br /> Q Service Station Q Hauler Q Agriculture Q Shredder ® Other ©moo _f t��, Lie4& _", <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 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 /> Q Q 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 <br /> Q Q 14 CCR§18459.2.1 -Submittal of Comprehensive Trip Logs within 90 days (Required for NOV or EX7] <br /> a <br /> Q Q 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 Q Referred/CalRecycle Enforcement <br /> Q 0 14 CCR§18461 -Manifest System Requirements for Waste Tire End-Use Facilities W <br /> Q O 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators In Compliance No Violations o <br /> Q Q Other:§ <br /> Comments ` <br /> Lr,;-� r-1l~��it�'� Lw�� <br /> • 7 ;Cnrl• /)�! -4y �Ql.•!�i✓//m fig CYt�'_—77Y-�e�,,d a f f-G- .h 1T/..� g cy . i h <br /> ✓13 4 e, �5 &-,Ar_ C&t.inti VVU Zff,27� •-4y�> 92 S_/y/_ el C--m a7,— err l <br /> s, � Vn % "Tp i73 6 0-c2� CyI .(0 ; J�w� 1�+�[ut <br /> inspection Form Included: Q Cft/yVi rLl�,�l t c q- <br /> Comments Included: Q y -� <br /> -- Business Rep's Signature I. Phone Number sa tots Signature Phone Number <br /> INSTRUCTIONS ON BACK Correct:0 Incorrect: E X A P L E 11213 62081 <br /> ■ White Copy:CalRecycle Yellow Copy:Operator Pink Copy: ® ■ <br />