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Waste Tire Su. vey & Inspection Repor0inspection Report Number <br /> cal Rec cle State of California <br /> Y CalRecycle181(Rev.10/10) Survey Form - Page 1 I1 1230000 <br /> Dept of Resources Recycling and Recovery(CalRecycle) <br /> Part A-Survey BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- I - ` Inspection Type(Fill one) <br /> Site Suffix: ` 0 Routine 0 Re-inspection 0 Referral 0 Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier: ;� 'J' <br /> ^ / 0 CHP 0 CalRecycle 0 Complaint 0 Educational Visit 0 Other <br /> Business or Facility Name Inspected By Inspector <br /> Q GM \�" Axle, �v`C a I d 1 u <br /> Physical Address M <br /> Inspection Date C) <br /> 720 <br /> Time In Time Out <br /> Business Rep Title 0 AM 0 AM <br /> PM ! PM <br /> JCC, �� , <br /> Operational Status Tire Type Business Role Storage Type <br /> Tire Count (Whole/PTE) (FII 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 0 Closed 0 Altered <br /> GPS Latitude 9 Hauler 0 Indoor <br /> O 0 Inactive 0 Truck <br /> Longitude - 0 Planned 0 OTR 0 End-Use 0 Container <br /> Business Type(Fill all that apply) <br /> 0 New Tire Dealer 0 Auto Repair 0 Trucking Fleet 0 Government 0 Retreader 0 Dismantler 0 Tire Derived Fuel <br /> 0 Used Tire Dealer 0 Auto Body 0 Car Dealer 0 Collection 0 Crumb Rubber <br /> 0 Service Station 0 Hauler 0 Agriculture 0 Shredder 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 /> Notice Of Violation 0 Extension <br /> 0 0 PRC§42951 -Waste Tire Hauler Registration and Transport of Tires <br /> 0 0 PRC§42953-Contracts with Registered Waste Tire Haulers. Compliance Deadline <br /> PRC§42956-Registration/Decal in Vehicle <br /> 00 14 CCR§18459-Responsible Entities Complying with Manifesting Requirements Date Mob <br /> 0 0 14 CCR§18459.1 -Tire Program ID Number from CalRecycle <br /> 0 0 14 CCR§18459.2.1 -Submittal of Comprehensive Trip Logs within 90 days (Required for NOV or EXTj n <br /> 0 0 14 CCR§18459.3-Retention of Comprehensive Trip Logs for 3 years <br /> 0 0 14 CCR§18460.2-Manifest System Requirements for Registered Waste Tire Haulers 0 Referred/CalRecycle Enforcement <br /> 0 0 14 CCR§18461 -Manifest System Requirements for Waste Tire End-Use Facilities u, <br /> 0 0 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators 0 In Compliance-No violations o <br /> 0 0 Other:§ r ` <br /> CSI <br /> Comments �O%hv C0 v\ Y\e—`lp�S �C � OY\ <br /> d� <br /> — <br /> e� �e_r, -- - — <br /> Inspection Form Included: ow _3 J .494�_001-7CL] Q <br /> X1 c Uri w p <br /> Comments Included- <br /> Business Rep's Signature Phone Number Inspecto 's Signature Phone Number <br /> INSTRUCTIONS ON BACK I Correct: Incorrect: EXAMPLE 1 2 3 62081 <br /> white Copy:CalRecycle Yellow Copy:Operator Pink Copy:LEA <br />