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Oa Waste Tire Survey & Inspection Report Inspection Report Number <br /> CalRecycle State of CaliforniaI 1 - 1230285 <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- I Inspection Type(Fill one) <br /> Site Suffix: 0 Routine Q Re-inspection Q Referral Q Observation <br /> Local I ,- � If Referral,choose referral type(Fill one) <br /> Identifier: �Ck^ 3CU Ok lei r\ Q CHP Q CalRecycle Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name Inspected By Inspector <br /> Physical Address <br /> Inspection Date <br /> �5330 <br /> Time In Time Out <br /> Business Rep Title C O AM O AM <br /> ��t1 �� P+r10�G1. �Alo� rn r. J 0 PM 3 I 5 ® 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 /> 10 Active Q Passenger ® Generator Q Outdoor <br /> o Q Closed Q Altered N/,qGPS Latitude _ Q Hauler Q Indoor <br /> o Q Inactive Q Truck <br /> Longitude - Q Planned ® OTR Q End-Use Q Container <br /> Business Type(Fill all that apply) F01If <br /> 41 <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 n., <br /> Q Service Station Q Hauler Q Agriculture Q Shredder ® Other 1'� ��1Q (P)W141,G�1�1 1 <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) 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 I&In Compliance-No Violations o <br /> Q Q Other:§ __ <br /> Comments N.AJ f/LJ& .�L*,)n 5 i9,e�rU-A u n <br /> k�1\OW�� wuS rbcs <br /> Na N1UtaU 4U-1S. Q1 CAJc- ,4$ cTJ' C,Uf1ce-in- <br /> Inspection Form�ncludjd <br /> nclud2n9 Y� Sy <br /> /-O6 <br /> Iv1h� v + <br /> Comments <br /> B siness Rep's S' atur Phone Number Insp tor's Sign- Phone Number <br /> 62081 <br /> INSTRUCTIONS ON CK Corre Incorrect: X q EXAM 1 2 3 <br /> ■ White Copy:CalRecycle Yellow Copy:Operator Pink Copy: ® ■ <br />