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Waste Tire Survey & Inspection Report Inspection Report Number <br /> cle State of California <br /> CalRecycle CalRecycle 181(Rev.10/10) Survey Form - Page 1 11 - 1210389 <br /> Dept.of Resources Recycling and Recovery(CalRecycle) <br /> Part A-Survey BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- �7 \A Inspection Type(Fill one) <br /> Site Suffix: I S L I g 0 Routine Q Re-inspection Q Referral Q Observation <br /> Local r— If Referral,choose referral type(Fill one) <br /> Identifier: �C1V\ J Oe-.Ifj V 4Y_ <br /> `�L Q CHP Q CalRecycle Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name I _ Inspected By Inspector <br /> Physical Address AT <br /> �;700 <br /> SA-0C <br /> _\e <br /> q Inspection Date S / L 7 / I <br /> � ��2� 1 Time In Time Out <br /> Business Rep Title S I O AM O AM <br /> v� S Z . � S <br /> 0 PM ® PM <br /> dol, fv y�"��n- wr�c <br /> Operational Status Tire type Business Role Storage Type <br /> Tire Count(Whole/PTE) / 0 (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> (7 0 Active 0 Passenger 0 Generator 0 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 • Container <br /> Business Type(Fill all that apply) <br /> Q New Tire Dealer i 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 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 / 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 EXT) 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 /> LU <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 Q Other:§ <br /> Comments Vi2ok`VNIZ L0,c S �'� e '%'KS9e_C �;rr 0" O�`s &CAC _ N <br /> - - <br /> Inspection Form Included: 0A75,1 .- <br /> Comments Included: <br /> — Zcy <br /> Business Re nature Phone Number Insp ctor's Signature Phone Number <br /> INSTRUCTIONS ON BACK orrect: Incorrect: EXAMPLE 1112 3 62081 <br /> White Copy:CalRecycle Yellow Copy:Operator Pink Copy:LEA <br />