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Waste Tire Survey & Inspection Report Inspection Report Number ■ <br /> CalRec cle state of California — <br /> Y CalRecycle 181(Rev.10/10) Survey Form - Page 1 I1 1196746 <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- `77 I Inspection Type(Fill one) <br /> Site Suffix: 3 1 0 o ` ® Routine Q Re-inspection Q Referral Q Observation <br /> Local r If Referral,choose referral type(Fill one) <br /> Identifier: �O-Y\ J q y\ Cd v.n 0 CHP Q CalRecycle Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name 4 Inspected By Inspector <br /> Pk��� 2S. 9 _ 1 I ,� T v <br /> Physical Addressss <br /> 1 S'-ts 3 &). `Cvocr�o vn Vc\'�'- - - <br /> Cly GS2`�2 - <br /> Inspection Date © 2 5 / <br /> Time In Time Out <br /> Business Rep Title 0 AM ( \ O AM <br /> l \ ' ' S O PM V 0 PM <br /> - - Operational Status Tire Type Business Role Storage Type <br /> Tire Count (Whole/PTE) 2 (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> 0 Active O Passenger 0 Generator 08 Outdoor <br /> O Q Closed Q Altered <br /> GPS Latitude Q Hauler 0 Indoor <br /> o Q Inactive 0 Truck <br /> Longitude - Q Planned O OTR O End-Use Q Container <br /> Business Type(Fill all that apply) <br /> 0 New Tire Dealer Q 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 O Agriculture Q Shredder 0 Other Ir"Cl. Ora <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 � Extension <br /> O O <br /> PRC§42951 -Waste Tire Hauler Registration and Transport of Tires <br /> O O PRC§42953-Contracts with Registered Waste Tire Haulers. Compliance Deadline <br /> O O PRC§42956-Registration/Decal in Vehicle <br /> Q O 14 CCR§18459-Responsible Entities Complying with Manifesting Requirements Date m / m <br /> 0 O 14 CCR§18459.1 -Tire Program ID Number from CalRecycle N <br /> Q O 14 CCR§18459.2.1 -Submittal of Comprehensive Trip Logs within 90 days (Required for NOV or EXT) N <br /> O O 14 CCR§18459.3-Retention of Comprehensive Trip Logs for 3 years o <br /> O O 14 CCR§18460.2-Manifest System Requirements for Registered Waste Tire Haulers Q Referred/CalRecycle Enforcement <br /> w <br /> Q O 14 CCR§18461 -Manifest System Requirements for Waste Tire End-Use Facilities <br /> 0 O 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators In Compliance-No Violations o <br /> Q Q LOther§ z <br /> _ 4 <br /> Comments <br /> y%n �.� ov�S oc Aceo.S cl�N <br /> Inspection Form Included: Q � V <br /> Comments Included: <br /> Busine s Rep'sPure hone Number Inspector's Signature Phone Number <br /> INSTRUCTIONS ON BACK [Correct:0 Incorrect: EXAMPLE I 1112 3 62081 <br /> ■ White Copy:CalRecycle Yellow Copy:Operator Pink Copy:LEA ® ■ <br />