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Waste Tire Survey & Inspection Report Inspection Report Number <br /> Cal Rec cle State of California <br /> Y CalRecycle 181(Rev.10/10) <br /> (Cal Survey Form - Page 1 I1 1245137 <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 Type(Fill one) <br /> Site Suffix: I `-� �! lP� Q Routine Q Re-inspection Q Referral Q Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier: Q CHP Q CalRecycle Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name Inspected By Inspector <br /> A-r -voar l <br /> Physical Address Z) � - 1 () / 54NOUvAb W l <br /> Inspection Date � � 2- S- 1 1 S <br /> SClv�r� C <br /> Time In Time Out <br /> Business Rep TitleO AM _3 �AM <br /> `� <br /> PM <br /> Operational Status Tire Type Business Role Storage Type <br /> 2 <br /> Tire Count ho /PTE) / (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> / O Active 4P Passenger 4D Generator i Outdoor <br /> O Q Closed Q Altered <br /> GPS Latitude Q Hauler Q Indoor <br /> O Q Inactive Q Truck <br /> Longitude - Q Planned Q OTR Q End-Use Q Container <br /> Business Type(Fill all that apply) <br /> A New Tire Dealer 0 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 Q Extension <br /> Q Q <br /> 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 <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 E?Cl) N <br /> a <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 e In Compliance-No Violations o <br /> Q Q Other:§ <br /> Comments VzXt_z0K_P_ CL)CP �e �GtSL tyL1L/2kE ,.f,,,_ , C/YLT�C�A li ¢Q Q <br /> V't 2.OLc4,13 (D - <br /> Inspection Form Included: Q Tooi _7� <br /> Comments Included: ® r O <br /> Toy -/oil <br /> Busines ep s Signature Phone ube <br /> mr Inspector's Signature Phone Number <br /> �-,( <br /> XNJ <br /> INSTRUCTIONS ON BACK Correct:0 Incorrect: EXAMPLE 2 3 62081 1 <br /> ■ White Copy:CalRecycle Yellow Copy:Operator Pink Copy:LEA <br />