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Waste Tire Survey & Inspection Reporc Inspection Report Number ■ <br /> CalRecycle State of California 11 - 1226529 <br /> CalRecycle 181(Rev.10/10) Survey Form - Page 1 <br /> Dept.of Resources Recycling and Recovery(CalRecycle) <br /> Part A-Survey--- BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- f I - © I Inspection Type(Fill one) <br /> Site Suffix: �q ® Routine Q Re-inspection Q Referral Q Observation <br /> Local ( If Referral,choose referral type(Fill one) <br /> Identifier: W� Cnu��� Q CHP Q CalRecycle Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name Inspected By Inspector <br /> - I I <br /> Physical Address 0CjLvr !\ <br /> Inspection Date , / a V <br /> / I I <br /> (CAMP Time In Time Out I I <br /> Business Rep Title O AM0 AM <br /> l _ ® PM O PM <br /> Operational Status Tire Type Business Role Storage Type <br /> Tire Count(Whole/PTE) r� (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> ® Active Q Passenger ® Generator &Outdoor <br /> Q Closed Q Altered <br /> GPS Latitude Q Hauler Q 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 -® 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 lli-,Li t prttl <br /> j- <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 m <br /> Q Q 14 CCR§18459.1 -Tire Program ID Number from CalRecycle i <br /> Q O 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 <br /> Q Q 14 CCR§18460.2-Manifest System Requirements for Registered Waste Tire Haulers Q Referred/CalRecycle Enforcement <br /> 2 <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 /> Comments �411X N LAS �1 � / On A,, i1 , d /), N <br /> k_/Q <br /> No Via c�� caS_ c6n- <br /> Inspection Form Included: Q ,Q C ^,� <br /> Comments Included: C1v1) lt(L0 �7� <br /> Business Rep's gnature Phone Number Inspe is Signature Phone Number <br /> � <br /> INSTRUCTIONS ON ACK Correct: Incorrect: ( I E I^ A 62081 <br /> M L 1 2 3 <br /> ■ White Copy:CalRecycle Yellow Copy:Operator Pink Cop <br />