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144 <br /> Oa Waste Tire Su vey & Inspection Reporonspection Report Number <br /> cle State of California <br /> CalRecycle — <br /> Y CalRecycle 181(Rev.10/10) Survey Form - Page 1 I1 1245027 <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 I Inspection Type(Fill one) <br /> 7 Site Suffix: G 0l . Routine Q Re-inspection Q Referral Q Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier: �ari �i�.n n v�� v� Q CHP Q CalRecycle Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name Inspected By Inspector <br /> C�VIAV6 -2 <br /> Physical Address <br /> vl$ 27 G.d�S 5�r• <br /> C Inspection Date <br /> �r " <br /> \_aL� � O Time In Time Out <br /> Business Rep Title � � � :AM � t � � 0 AM <br /> 6�� �� �j •�� PM 0 PM <br /> Operational Status Tire Type Business Role Storage Type <br /> Tire Count(Whole/PTE) t, (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> ID Active 0 Passenger 0 Generator *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 /> Q New Tire Dealer Q Auto Repair Q 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 0 Other %sk- <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 <br /> Q Q 14 CCR§18459.2.1 -Submittal of Comprehensive Trip Logs within 90 days (Required for NOV or EXE <br /> Q Q 14 CCR§18459.3-Retention of Comprehensive Trip Logs for 3 years In <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 LI, <br /> V Y VV11 <br /> \J I&In Compliance-No Violations o <br /> Q Q Other:§ 1 ` <br /> Comments . C5 01_ Je_ WaJVV k i t'P— i ay a'h flint <br /> Aa <br /> 0 <br /> Inspection Form Included: Q z04, <br /> Comments Included:a — ---- 7—% ,f/I/�'• ZQ`� �r� <br /> Business Re Signa hone Number Inspedror's Signature Phone Number <br /> INSTRUCTIONS ON BACK Correct:0 Incorrect: jEjXjAjM� PjLjEj 1112 3 62081 <br /> ■ White Copy:CalRecycle Yellow Copy:Operator Pink Copy:LEA <br />