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x Waste Tir*urvey & Inspection Re[,vr`i Inspection Reporc Number <br /> cle State of California <br /> CalRecycle CalRecycle 181(Rev.y(Coal Survey Form <br /> Page 1 I 1 1245199 <br /> Dept of Resources Recycling and Recovery(CalRecycle) <br /> Part A-Survey BLUE OR BLACK INK_ PEN <br /> Business Profile Inspection Details <br /> TPID- inspection Type(Fill one) <br /> 4 <br /> Site Suffix: LCJ 1 1 0 Routine Q Re-inspection Q Referral Q Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier: `7 7caq u 6 n Q CHP Q CalRecycle Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name Inspected By Inspector <br /> Physical Address 3 9 - C) 1 S�1 r'v 1-_')C)V if Z_ F-{' <br /> ZC - <br /> Cii- 153 3 Inspection Date j I / / l51 <br /> li y Time In Time Out <br /> Business RepTittle �0 AM t` �'O AM <br /> A�;Pce..rn �Y-ZG%( lX[z.i T-'V?-� . e PM � �j ® 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 /> V 0 Active Q Passenger 0 Generator Q Outdoor <br /> O Q Closed Q Altered <br /> G�� Latitude Q Hauler 0 Indoor <br /> O Q Inactive • Truck <br /> Longitude - Q Planned Q OTR i 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 7YGt�trf i�r Ex.KIC� <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 N <br /> Q Q 14 CCR§18459.2.1 -Submittal of Comprehensive Trip Logs within 90 days (Required for NOV or EXT) N <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 <br /> In Compliance-No Violations o <br /> Q Q Other:§ <br /> z <br /> Comments lM N <br /> 1 <br /> Inspection FormIncluded: Q 2017 <br /> Comments Included: <br /> Business Rep's Signature Phone Number Inspe is Signature Phone Number <br /> INSTRUCTIONSON BACK Correct:0 Incorrect: IEIXIAIMIPILIEI 1112 3 62081 <br /> ■ White Copy:CalRecycle Yellow Copy:Operator Pink Copy:LEA ® ■ <br />