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Waste Tire Survey & Inspection Report Inspection Report Number <br /> CalRecycle state of California <br /> Y CalRecycle 181(Rev.10/10) Survey Form - Page 1 11 - 1210473 <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 O Inspection Type(Fill one) <br /> O <br /> Site Suffix: 1 ® Routine Q Re-inspection Q Referral Q Observation <br /> Local �— I /� If Referral,choose referral type(Fill one) <br /> Identifier: spl rl J O f f1 1 (�U1! �� Q CHP Q CalRecycle Q Complaint Q Educational Visit Q Other <br /> Business or Facility Nall <br /> By Inspector <br /> _ ( d � <br /> Physical Address ES cOTTfD <br /> C� Inspection Date <br /> Time In Time Out <br /> Business Rep Title 1 Q Q e AM I 'S AM <br /> ` 0 PM 0 PM <br /> Operational Status Tire Type Business Role Storage Type <br /> Tire Count (Whole/PTE) !�f (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> �(J Q Active Q Passenger Q nGenerator Q Outdoor <br /> 0 0 Closed Q Altered A <br /> GPS Latitude � <br /> O Q Inactive Q Truck Q Hauler Q Indobr <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 0 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 Q PRC§42951 -Waste Tire Hauler Registration and Transport of Tires Q Notice Of Violation Extension <br /> Q Q PRC§42953-Contracts with Registered Waste Tire Haulers. Compliance Deadline <br /> PRC§42956-Registration/Decal in Vehicle <br /> QQ 14 CCR§18459-Responsible Entities Complying with Manifesting Requirements Date IT] / 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 EXE 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 /> 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 0 In Compliance-No Violations <br /> Q 1 Q 1 Other:§ <br /> Comments VI2 r�A_ �r�' jjrx ) 0=n �� JAIL, �'ln'A 1/\ N <br /> nokul'- <br /> i vl ti 1 T C" el'(1 <br /> �c•- �. F ' ' 'a tan �.>� � � 11tr� �0� i cam. C aJ�.Sc Pte. <br /> Inspection Form Included: Q <br /> Comments Included: Q <br /> Business Rep's Signature Phone Number Ins ctor's Signatur Phone Number <br /> INSTRUCTIONS ON BACK Correct:41 Incorrect: X c NJ E X A 112 3 62081 <br /> ® White Copy:CalRecycle Yellow Copy:Operator Pink C py: © ■ <br />