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Oa Waste Tire Survey & Inspection Repon Inspection Report Number <br /> State of California <br /> CalRecycle — <br /> CalRecycle 181(Rev.10/10) Survey Form - Page 1 I1 1230314 <br /> Dept.of Resources Recycling and Recovery(CalRecycle) <br /> Part A- SurveLr BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- -7 d w Inspection Type(Fill one) <br /> Site Suffix: ( L 9 Routine Q Re-inspection Q Referral Q Observation <br /> Local /'� If Referral,choose referral type(Fill one) <br /> son o n V 0M�Lt 1 v, Q CHP Q CalRecycle Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name Inspected By Inspector <br /> Physical Address - ' Cs <br /> q,15 rj Tnor4o-\ ZA , V <br /> Inspection Date / 1 1 S <br /> SAo c,�C'U-/" Lfl �Szo1 <br /> Time In Time Out <br /> Business Rep TitleM * AM * AM <br /> lj� \- ( 1 ` t1/�nit T S 0 Q PM 1 O PM <br /> �V t r 1ANC4 � C <br /> Operational Status Tire Type Business Role Storage Type <br /> Tire Count (Whole/PTE) Q (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> ® Active • Passenger &Generator ® 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 Q Container <br /> Business Type(Fill all that apply) <br /> 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 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 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 EXE N <br /> a <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 /> 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 /> 01 Q Other:§ <br /> CommentsQ_0�l req W m s� <br /> �v ll c�vJ A� LA)t ,s 'n" <br /> 4�1� VAoGI �c)ns 0S CA5 ac Co'�[er <br /> Inspection Form Included: Q �,tr's <br /> 20Comments Included: 0 — / ,usiness Rep's Signature Phone Number Insnatur Phone Number <br /> INSTRUCTIONS ON BACK Correct:0 Incorrect: JE�XJA�Mk LJyj 111213] 62081 <br /> ■ <br /> opy <br /> White Copy:CalRecycle Yellow Copy:Operator Pink CLE © ■ <br />