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r <br /> Waste Tire Suivey & Inspection Report Inspection Report Number <br /> CalRecycle State of California <br /> Y CalRecycle 181(Rev.10/10) Survey Form - Page 1 I1 — <br /> 12 3 0 3 2 7 <br /> Dept.of Resources Recycling and Recovery(CalRecycle) <br /> Part A-Survey BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- O � Inspection Type(Fill one) <br /> Site Suffix: V 0* Routine Q Re-inspection Q Referral Q Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier: O CHP Q CalRecycle Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name Inspected By Inspector <br /> E <•r <br /> \ C&\ ,,n0 7� ,Gs Cc�aa.�E�� �►vf3 - <br /> Physical Address <br /> Inspection Date '1 2 <br /> -K°o GA gStibL _4 <br /> Time In Time Out <br /> Business Rep ll Title /� ® AM � � I ■ � O PM <br /> V <br /> ` �51 p O PM l_elf <br /> Operational Status Tire Type Business Role Storage Type <br /> Tire Count(Whole/PTE) j� (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> 0 0 ® Active ® Passenger ® Generator ® Outdoor <br /> O Q Closed O Altered <br /> GPS Latitude Q Hauler Q Indoor <br /> O Q Inactive O Truck <br /> Longitude — Q Planned Q OTR O End-Use Q Container <br /> Business Type(Fill all that apply) <br /> New Tire Dealer Q Auto Repair Q Trucking Fleet Q Government Q Retreader Q Dismantler Q Tire Derived Fuel <br /> ® 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 � Extension <br /> O O <br /> PRC§42951 -Waste Tire Hauler Registration and Transport of Tires <br /> O O PRC§42953-Contracts with Registered Waste Tire Haulers. Compliance Deadline <br /> PRC§42956-Registration/Decal in Vehicle <br /> O O 14 CCR§18459-Responsible Entities Complying with Manifesting Requirements Date m <br /> O O 14 CCR§18459.1 -Tire Program ID Number from CalRecycle <br /> O O 14 CCR§18459.2.1 -Submittal of Comprehensive Trip Logs within 90 days (Required for NOV or EXEC? <br /> O ® 14 CCR§18459.3-Retention of Comprehensive Trip Logs for 3 years <br /> O O 14 CCR§18460.2-Manifest System Requirements for Registered Waste Tire Haulers Q Referred/CalRecycle Enforcement <br /> 2 <br /> O 0 14 CCR§18461 -Manifest System Requirements for Waste Tire End-Use Facilities W <br /> O O 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators is In Compliance-No Violations o <br /> Q O Other:§ t (, 1 <br /> Comments 3�J VNm b�. ,�' r� i n 1 lr C6np Qr� al1 ts d.eft 111110 QJ Q 11tL �1� <br /> Inspection Form Included: Q <br /> "mber <br /> Comments Included: ® — <br /> siness a natu Phone NuInspe t is Signature Phone Number <br /> 62081 <br /> INSTRUCTIONS ON BAC Correct:* Inc rrect: 7V EXAM L 1 2 3 <br /> ■ White Copy:CalRecycle Yellow Copy:Operator Pink Copy L © ■ <br />