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Waste Tire Su,vey & Inspection Report Inspection Report Number <br /> CalRecycle State of California — <br /> CalRecycle 181(Rev.10/10) Survey Form - Page 1 11 1230417 <br /> Dept.of Resources Recycling and Recovery(CalRecycle) <br /> Part A-Survey BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- Inspection� ` O � - � I Inspection Type(Fill one) <br /> Site Suffix: ` * Routine Q Re-inspection Q Referral Q Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier: r10 V� Q CHP Q CalRecycle Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name \1 Inspected By Inspector <br /> Qco��e�e� J2 C\ - <br /> Physical Address <br /> 1 ikAS--'� IV. <br /> �SZ`12 <br /> Inspection Date O / 2 6 1 <br /> Time In Time Out <br /> Business Rep Title ' I AM 0 AM <br /> Q PM I C) 0 &PM <br /> Operational Status Tire Type , Business Role Storage Type <br /> Tire Count(Whole/PTE) r, (Fill one only) (Fill all that apply)! (Fill all that apply) (Fill all that apply) <br /> 0 Active Q Passenger • Generator 40 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 /> New Tire Dealer Q Auto Repair Q Trucking Fleet Q Government Q Retreader Q :woe► 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 Q Agriculture Q Shredder 0 Otherr4 S L <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 /> Q Q PRC§42956-Registration/Decal in Vehicle <br /> Q Q 14 CCR§18459-Responsible Entities Complying with Manifesting Requirements Date !/ m / m <br /> Q Q 14 CCR§18459.1 -Tire Program ID Number from CalRecycle II II II <br /> Q O 14 CCR§18459.2.1 -Submittal of Comprehensive Trip Logs within 90 days (Required for NOV or EXE N <br /> Q Q 14 CCR§18459.3-Retention of Comprehensive Trip Logs for 3 years <br /> 0 <br /> Q O 14 CCR§18460.2-Manifest System Requirements for Registered Waste Tire Haulers Q Referred/CalRecycle Enforcement <br /> 2 <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 /> 010 Other:§ <br /> Comments <br /> VA <br /> Inspection Form Included: Q 'Zoq—Y6&- <br /> 6 p� 3 <br /> Comments Included: 'iQ(, — <br /> Bu ess Rep's Signatu Phone Number Inspector's Signature Phone Number <br /> �-,( 62081 <br /> INSTRUCTIONS ON BACK Correct: Incorrect: X NJ E X A M P L E 1112 3 <br /> White Copy:CalRecycle Yellow Copy:Operator Pink Copy:LEA <br />