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0 Waste Tire Su, vey & Inspection Report Inspection Report Number ■ <br /> CalRecycle State of California _ <br /> Y CalRecycle 181(Rev.10/10) Survey Form - Page 1 11 1229940 <br /> Dept.of Resources Recycling and Recovery(CalRecycle) <br /> Part A-Survey BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- S _ 0 Inspection Type(Fill one) <br /> Site Suffix: 4 S (� 1 , Routine Q Re-inspection Q Referral Q Observation <br /> Local r� t If Referral,choose referral type(Fill one) <br /> Identifier: J 0 Cep V Y\. (v y%\—/ Q CHP Q CalRecycle Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name ( Inspected By Inspector <br /> C� Tn.C. 2 p _ C> r� V <br /> Physical Address o� 7 1 <br /> Inspection Date o Z / 9 <br /> S CN< �-Ov <br /> Time In Time Out <br /> Business Rep TitleZ� Q � C5 O PM � 1 / Q AM V QPM <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 /> 1 7 40 Active. 0 Passenger 9 Generator S Outdoor <br /> O Q Closed Q Altered <br /> GPS Latitude Q Hauler Q Indoor <br /> O Q Inactive 0 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 ® Other TdW 'FOe:rA- <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 / m / m <br /> Q Q 14 CCR§18459.1 -Tire Program ID Number from CalRecycle N <br /> Q Q 14 CCR§18459.2.1 -Submittal of Comprehensive Trip Logs within 90 days (Required for NOV or EXT) N <br /> a <br /> N <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 /> W <br /> Q Q 14 CCR§18461 -Manifest System Requirements for Waste Tire End-Use Facilities <br /> Q Q 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators o In Compliance-No Violations o <br /> Q Q Other:§ <br /> Comments CLz <br /> Inspection Form Included: Q <br /> Comments Included: ` <br /> u ess Rep's Signa r Phone Number nspect is Signature Phone Number <br /> INSTRUCTIONS ON BACK Correc .Incorrect: IEIXIAIMIPILIEI 1112 3 62081 <br /> White Copy:CalRecycle Yellow Copy:Operator Pink Copy:LEA <br />