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+rf.�I/fi'Ff.' +=%rif.%llf rT3.{.??q,{:l! e!?-.'..�:?_•.f.{ij}` ? 1/ .?rf - fr.__:: _., :-: F�rff%llr-.%-ri7j # ...:lfJifr'ffff%�.^r <br />2 Waste Tire Survey & Inspection Report Inspection Report Number ■ <br />CalRecycle State of California 11-1176469 <br />CalRecycle 181 (Rev. 10/10) Survey Form -Page 1 <br />Dept. of Resources Recycling and Recovery (CalRecycle) BLUE OR BLACK INK PEN <br />rdr f. M - aUK vcr-- — -- --- - <br />Business Profile <br />Inspection Details _ <br />Inspection Type (Fill one) <br />TPID - <br />Site Suffix: ID I, � � I <br />41 Routine Q Re -inspection Q Referral Q Observation <br />If Referral, choose referral type (Fill one) <br />Local /, <br />�`�V L <br />Q CHP Q CalRecycle Q Complaint Q Educational Visit Q Other <br />Identifier: <br />Business or Facility Name <br />Inspected By Inspector <br />Address <br />3 <br />Physical <br />Inspection Date 2 / l L) I <br />CA 01,69-J <br />Time In Time Out 1( <br />Business Rep Title <br />0 AM ®AM <br />O PM 0 PM <br />Operational Status <br />(Fill one only) <br />Tire Type <br />(Fill all that apply) <br />Business Role <br />(Fill all that apply) <br />Storage Type <br />(Fill all that apply) <br />Tire Count (Whole/PTE) > > ! © 0 <br />40 Active <br />Q Closed <br />®Passenger <br />Q Altered <br />®Generator <br />Q Hauler <br />0 Outdoor <br />Q Indoor <br />O <br />Cies Latitude <br />Q Inactive <br />Q Truck <br />Longitude - <br />Q Planned <br />Q OTR <br />Q End-use <br />Q Container <br />Business Type (Fill all that apply) <br />Q Q Government Q Retreader ®Dismantler Q Tire Derived Fuel <br />Q New Tire Dealer Q Auto Repair Trucking Fleet <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 Q Other <br />Part B - <br />Inspection of Waste Tire Dealer, Generator, Hauler and End -Use Facility <br />ENFORCEMENT STATUS <br />AND MANIFEST REQUIREMENTS <br />VMHAULING <br />Q Notice Of Violation Q Extension <br />- Waste Tire Hauler Registration and Transport of TiresQ953 <br />Q951 <br />- Contracts with Registered Waste Tire Haulers. <br />Compliance DeadlineQ956 <br />- Registration/Decal in Vehicle/ <br />/Q <br />18459 - Responsible Entities Complying with Manifesting Requirements <br />Date m m <br />Q Q <br />14 CCR § 18459.1 - Tire Program ID Number from CalRecycle <br />(Required for NOV or EXT) <br />Q Q <br />14 CCR § 18459.2.1 - Submittal of Comprehensive Trip Logs within 90 days <br />Q Q <br />14 CCR § 18459.3 - Retention of Comprehensive Trip Logs for 3 years <br />Q Referred /CalRecycle Enforcement <br />Q Q <br />14 CCR § 18460.2 -Manifest System Requirements for Registered Waste Tire Haulers <br />Q Q <br />14 CCR § 18461 - Manifest System Requirements for Waste Tire End -Use Facilities <br />Q Q <br />14 CCR § 18462 - Manifest System Requirements for Tire Dealers or Waste Tire Generators <br />® In Compliance - No Violations <br />Q Q <br />Other: § <br />Comments <br />Inspection Form Included: Q <br />Comments Included: 0 Business Rep's Sign Phone Number • Ins e t 's I -ature leoo�_ Phone Number <br />L------ 62081 <br />INSTRUCTIONS ON BACK Correct: Incorrect: E X A 1 2 3 <br />White Copy: CalRecycle yellow Copy: Operator Pink C py: L <br />■ <br />