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-- <br /> Waste Tire Survey & Inspection Report Inspection Report Number <br /> CalRecycle State of California I 1 - 1242354 <br /> CalRecycle 181(Rev.10/10) Survey Form - Page � <br /> Dept.of Resources Recycling and Recovery(CalRecycle) <br /> BLUE OR BLACK INK PEN <br /> Part A-Surve <br /> Business Profile Inspection Details <br /> TPID- r 2 (� Inspection Type(Fill one) <br /> Site Suffix: V J CJ © •Routine Q Re-inspection Q Referral Q Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier: '2C,V', 3'00-1�v h Q CHP Q CalRecycle Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name r Inspected By Inspector <br /> Physical Address <br /> 2AcC_� `7 Z LOO—C—1 r. - — <br /> Inspection Date 0 2- / 1 .3 <br /> S�vL� n 5215; <br /> Time In Time Out <br /> Business Rep Title 1 C AM AM <br /> O PM 7 1 S 0 PM <br /> C,'\ <br /> — — -- - - -- Operational Status Tire Type Business Role Storage Type <br /> Tire Count (Whole/PTE) I (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> ' • Active 9 Passenger I&Generator lb Outdoor <br /> O Q Closed O Altered <br /> GpS Latitude Q Hauler 40Indoor <br /> o Q Inactive 0 Truck <br /> Longitude - Q Planned 0 OTR ® End-Use Container <br /> Business Type(Fill all that apply) <br /> jo New Tire Dealer 0 Auto Repair Q Trucking Fleet Q Government Q Retreader Q Dismantler Q Tire Derived Fuel <br /> 0 Used Tire Dealer 0 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 /> Notice Of Violation 0 Extension <br /> Q 0 PRC§42951 -Waste Tire Hauler Registration and Transport of Tires <br /> Q 0 PRC§42953-Contracts with Registered Waste Tire Haulers. Compliance Deadline <br /> Q 0 PRC§42956-Registration/Decal in Vehicle <br /> Q Q 14 CCR§18459-Responsible Entities Complying with Manifesting Requirements Date m / m <br /> 0 Q 14 CCR§18459.1 -Tire Program ID Number from CalRecycle <br /> 0 0 14 CCR§18459.2.1 -Submittal of Comprehensive Trip Logs within 90 days (Required for NOV or EX7 <br /> O 0 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 O Referred/CalRecycle Enforcement <br /> W <br /> O O 14 CCR§18461 -Manifest System Requirements for Waste Tire End-Use Facilities ___ _ <br /> O O 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators ®In Compliance- No Violations <br /> Q 0 Other:§ <br /> Comments y0 vr� W \ �OY> <br /> moo\, �o�n� d� �2�� �s-C�;•cQ.M. <br /> Inspection Form Included: Q -0&3 � ���� <br /> Comments Included: <br /> Rep's Signature Phone'llumber Inspector's Signature Phone Number <br /> 62081 <br /> INSTRUCTIONS ON BACK Correct: Incorrect: � W� E X A M P L E 1 2 3 <br /> ■ White Copy:CalRecycle Yellow Copy:Operator Pink Copy:LEA ® ■ <br />