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M Waste Tire Sup vey & Inspection Repori Inspection Report Number <br /> CalRec cle State of California <br /> Y CalRecycle 181(Rev.10/10) Survey Form - Page 1 I1 1196586 <br /> Dept of Resources Recycling and Recovery(CalRecycle) <br /> Part A-Survey BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- � ,.Z � h � � / _ a � Inspection Type(Fill one) <br /> Site Suffix: v p '6 Routine Q Re-inspection Q Referral Q Observation <br /> Local If Referral,choose referral type(Fill one) <br /> IdenYrfier: 5IcLr 0 mcU Q CHP Q CalRecycle Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name Inspected By Inspector <br /> ve' n <br /> ``99 c� 1 1 l <br /> Physical AddrSs � 3 R - I d M�� ` <br /> 125 S � Cov�w.e�ce S�� - V <br /> -- <br /> T` <br /> Inspection Date � 2 � 2 <br /> �ocSf:�o C �S2o <br /> Time In Time Out <br /> Business Rep Title 1AQ AM �7 O AM h l� ��I Q�O O W'I�QC O PM ' L o 0 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 /> "� • Active 0 Passenger * Generator Outdoor <br /> O Q Closed Q Altered <br /> Ca P$ Latitude 0 Hauler Q Indoor <br /> o Q Inactive Q Truck <br /> Longitude - Q Planned Q OTR 0 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 ! 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 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 /> Q Q 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 a <br /> Q Q 14 CCR§18459.2.1 -Submittal of Comprehensive Trip Logs within 90 days (Required for NOV or EX7) <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 .In Compliance No Violations o <br /> Q 1 Q 1 Other:§ <br /> z <br /> Comments <br /> r <br /> n Coves <br /> Inspection Form Included: <br /> Comments Included: . <br /> Business Rep's Signature Phone umber Inspector's Signature Phone Number <br /> INSTRUCTIONS ON BACK Correct:* Incorrect: IEIXIAIMIPILIEI 1112 3 62081 <br /> ■ White Copy:CalRecycle Yellow Copy:Operator Pink Copy:LEA ® ■ <br />