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Waste Tire Sup vey & Inspection Report Inspection Report Number <br /> CalRec cle State of California <br /> Y CalRecycle 181(Rev.10/10) Survey Form - Page 1 I1 1177706 <br /> Dept.of Resources Recycling and Recovery(CalRecycle) <br /> Part A- Survey -__ BLUE OR BLACK IN_ K PEN <br /> Business Profile Inspection Details <br /> TPID- Inspection Type(Fill one) <br /> Site Suffix: J Q ILI Q Routine Q Re-inspection Q Referral Q Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier: �GU1C�t�s �1� cE Leh, / Q CHP Q CalRecycle Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name t Inspected By Inspector <br /> Physical Address —` ( 0 f� LILI�L <br /> 17_30_) /11cavv Lj <br /> Inspection Date <br /> Time In Time Out <br /> Business Rep Title ®AM y / ® AM <br /> ( 0P t ( 0P <br /> Operational Status Tire Type Business Role Storage Type <br /> Tire Count(Whole/PTE) }{ (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> ' 1 S ® Active 4N Passenger &Generator 40 Outdoor <br /> Q Closed Q Altered <br /> GPS Latitude Q Hauler 0 Indoor <br /> O Q Inactive to Truck <br /> Longitude - Q Planned Q OTR Q End-Use Q 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 ® 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 <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 /> 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 EX7) N <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 Z <br /> LU <br /> LU <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 OIn Compliance No Violations o <br /> Q Q Other:§ <br /> Comments c , <br /> Inspection Form Included: Q <br /> Comments Included: Z 09 �I�S'�'10 L _cr <br /> Business Rep's Signature Phone Number p arOIgnpiure Phone Number <br /> INSTRUCTIONS ON BACK I Correct:* Incorrect: � � q IIEI-Xj A 1 1 111213 62081 <br /> ® White Copy:CalRecycle Yellow Copy:Operator Pink Cop :L ® ■ <br />