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•_ r <br /> Waste Tire Sup vey & Inspection Report Inspection Repoit:�aumber <br /> cle State of California <br /> CalRecycle CalRecycle 181(Rev.10/10) Survey Form - Page 1 11 - 1177505 <br /> Dept.of Resources Recycling and Recovery(CalRecycle) <br /> Part A-Survey _ BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- 1, H ( Inspection Type(Fill one) <br /> Site Suffix: I 3 + J 2, p Routine Q Re-inspection Q Referral Q Observation <br /> Local _� 1 �u� If Referral,choose referral type(Fill one) <br /> C <br /> Identifier: S n QU1 L4 1 r' Q CHP Q CalRecycle Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name l Inspected By Inspector <br /> c(Ati;i 0T(')11CA �n-kk+\­) �,,. ,of; 3 e I o ] <br /> Physical Address E SC 0�T <br /> 1 <br /> to C _1 Inspection Date L� / l r7 <br /> Time In Time Out <br /> Business Rep Title ® AM ®AM <br /> t 0 3- 0 O PM O PM <br /> �b� �o1i�� PCrSO -�- <br /> - Operational Status Tire Type Business Role Storage Type <br /> Tire Count (Whole/PTE) <br /> (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> � � q b <br /> 0 Active 0 Passenger ® Generator • Outdoor <br /> Q Closed Q Altered <br /> GPS Latitude Q Hauler Q Indoor <br /> O Q Inactive ® Truck <br /> Longitude - Q Planned Q OTR Q End-Use • Container <br /> Business Type(Fill all that apply) <br /> Q New Tire Dealer Q 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 O Other <br /> Part B- Inspection of Waste Tire Dealer,Generator, Hauler and End-Use Facility ENFORCEMENT STATUS <br /> V A I 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 0 14 CCR§18459-Responsible Entities Complying with Manifesting Requirements Date m <br /> Q Q 14 CCR§18459.1 -Tire Program ID Number from CalRecycle <br /> Q 0 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 N <br /> 0 <br /> Q 0 14 CCR§18460.2-Manifest System Requirements for Registered Waste Tire Haulers Q Referred/CalRecycle Enforcement <br /> W <br /> Q Q 14 CCR§18461 -Manifest System Requirements for Waste Tire End-Use Facilities W <br /> Q 0 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators <br /> In Compliance-No Violations o <br /> Q Q Other:§ <br /> Comments n �a � <br /> K,0� 1 r-10— u? <br /> 0 was <br /> Inspection Form Included: `� r1 <br /> Comments Included:® Care; <br /> B s ss Reps P o e Number Ins tor's Signature Phone Number <br /> INSTRUCTIONS ON BACK Correct: Incorrect: E X A L1 273 <br /> 62081 <br /> White Copy:CalRecycle Yellow Copy:Operator Pink CVA A <br />