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® 2 Waste Tire S ey & Inspection Repor{ nspection Report Number ■ <br /> CalRecycle State of California 41 - 1226554 <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 /> i Business Profile Inspection Details <br /> TPID- I _ I - ' Inspection Type(Fill one) <br /> O <br /> Site Suffix: ,Z 0 Routine 0 Re-inspection 0 Referral 0 Observation <br /> Local /� If Referral,choose referral type(Fill one) <br /> Identifier: JLbY► V w ( u 0 CHP 0 CalRecycle 0 Complaint 0 Educational Visit 0 Other <br /> Business or Facility Name T l� Inspected By Inspector <br /> A $ 1A _ <br /> Physical Address 3 ' Sc t:2TI <br /> rPOA WA <br /> Inspection Date I ( / © <br /> M U sti CA _ <br /> Time In Time Out <br /> Business Rep Title O AM O AM <br /> Q O PM a PM <br /> Operational Status Tire Type Business Role Storage Type j <br /> Tire Count(Whole/PTE) (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> 0 Active 0 Passenger 0 Generator 0 Outdoor <br /> Latitude O 0 Closed 0 Altered <br /> CIPS 0 Hauler 0 Indoor <br /> 0 0 Inactive ® Truck <br /> Longitude - 0 Planned 0 OTR 0 End-Use <br /> Container <br /> Business Type(Fill all that apply) <br /> NTire Dealer 0 Auto Repair 0 Trucking Fleet 0 Government 0 Retreader 0 Dismantler 0 Tire Derived Fuel <br /> 0 Used Tire Dealer 0 Auto Body 0 Car Dealer 0 Collection 0 Crumb Rubber <br /> 0 Service Station 0 Hauler 0 Agriculture 0 Shredder 0 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 /> -- — - - -- --- - - 0 Notice Of Violation 0 Extension <br /> 0 0 PRC§42951 -Waste Tire Hauler Registration and Transport of Tires <br /> 0 0 PRC§42953-Contracts with Registered Waste Tire Haulers. Compliance Deadline <br /> j0 0 PRC§42956-Registration/Decal in Vehicle <br /> 0 0 14 CCR§18459-Responsible Entities Complying with Manifesting Requirements Date I ' M3O <br /> / <br /> 0 0 14 CCR§18459.1 -Tire Program ID Number from CalRecycle <br /> 0 0 14 CCR§18459.2.1 -Submittal of Comprehensive Trip Logs within 90 days (Required for NOV or EXT/ n <br /> ® 0 14 CCR§18459.3-Retention of Comprehensive Trip Logs for 3 years o <br /> 0 0 14 CCR§18460.2-Manifest System Requirements for Registered Waste Tire Haulers 0 Referred/CalRecycle Enforcement <br /> 0 0 14 CCR§18461 -Manifest System Requirements for Waste Tire End-Use Facilities W <br /> 0 0 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators 0 In Compliance-No Violations <br /> 0 0 Other:§ ----- --- <br /> Comments <br /> —Pb14 <br /> Inspection Form Included: 0 <br /> Comments Included: mill, T --- —- -- --r <br /> �ector's <br /> Business Rep's Signature Phone Number nture Phone Number <br /> INSTRUCTIONS ON BACK [Correct:* Incorrect: M 4 ] E X A M P L 'E 1 2 3 62081 <br /> White Copy:CalRecycle Yellow Copy:Operator Pink Co : <br />