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Waste Tire Survey & Inspection Report inspection Report dumber <br /> State of California <br /> CalRecycle — r <br /> CalRecycle 181(Rev.10/10) Survey Form - Page 1 11 12 42348 <br /> Dept.of Resources Recycling and Recovery(CalRecycle) <br /> Part A-Survey BLUE OR BLACK INK PEN_ <br /> Business Profile Inspection Details <br /> TPID- ' t7 t1 n p _ I Inspection Type(Fill one) <br /> Site Suffix: ( I •C t ® Routine Q Re-inspection Q Referral Q Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier: S(�l Cl JU01�L1 fl f7'V1n Q CHP Q CalRecycle Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name Inspected By Inspector <br /> �� <br /> an e.e, cies mo�a� 3 _ I Q <br /> Physical Address 1 C�lioTT V <br /> \\� <br /> CA Inspection Date�i5�t�s 1 <br /> Time In Time Out <br /> Business Rep Title 0 " (� AM <br /> PM v O O 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 /> i Active Q Passenger ® Generator ® Outdoor <br /> Q Closed Q Altered <br /> CaP� Latitude Q Hauler ® Indoor <br /> O Q Inactive * 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 40 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 <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 /> Q Q 14 CCR§18459-Responsible Entities Complying with Manifesting Requirements Date 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) 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 /> Q Q 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 /> Commentsealkkin., woe j 1� ; f ISA U14 Ajj, N <br /> 7�ADAA)), nA L_A)-CAS ('� = f <br /> aL l (�S a s C,1 1cC.1S Com" (,13S)Le,3 <br /> Inspection Form Included: Q ��+�`�j,,,/j►'L}n �� X1108-31^� <br /> Comments Included: <br /> Rep's Signature Phone Number Ins tor's Signature Phone Number <br /> INSTRUCTIONS ON BACK Correct: Incorrect: 11 EIXIAIM4LI El I 1 I <br /> 2N <br /> 62081 <br /> White Copy:CalRecycle Yellow Copy:Operator Pink CopL54/ <br />