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Waste Tire Sup vey & Inspection Repon Inspection Report Number ■ <br /> Cal Rec cle State of California <br /> Y CalRecycle 181(Rev.10/10) Survey Form - Page 1 11 - 1176822 <br /> Dept.of Resources Recycling and Recovery(CalRecycle) <br /> Part A--..Survey__ _ _ BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- Inspection Type(Fill one) <br /> Site Suffix: ` "-1 -1 L-{ 0 l ® Routine Q Re-inspection Q Referral Q Observation <br /> LocalGL�,_� COLA <br /> If Referral,choose referral type(Fill one) <br /> Identifier: `��� �G�LA CO//• LA Q CHP Q CalRecycle Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name Inspected By Inspector <br /> Physical%dress U / <br /> Inspection Date <br /> p2CA G{,5366 c <br /> Time In Time Out <br /> Business Rep TitleI 1 O AM ®AM <br /> l PM 0 PM <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 /> Q Active Q Passenger ® Generator Q Outdoor <br /> O 9 Closed Q Altered` N/A <br /> GPS Latitude r'1 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 /> 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 Q — Q Notice Of Violation Q Extension <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 /> Q Q 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 CalRecycleLn <br /> Q Q 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 <br /> Q Q 14 CCR§18460.2-Manifest System Requirements for Registered Waste Tire Haulers Q Referred/CalRecycle Enforcement <br /> 2 <br /> W <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 <br /> in Compliance-No Violations o <br /> Q Q Other:§ <br /> Commentsfl-e�'Avy <br /> Nptnc.� ,1A�-CA-k�e`v����- - j ✓�1l. V_- <br /> 6e( <br /> - c�-.:f�• �,r,rZ c`.e s -�-� �� n [ <br /> 6ec � -if-c74r�l <br /> Inspection FormIncluded: Q , ? <br /> Comments Included: Q - -- - - - <br /> I _ Business Rep's Signature Phone Number Ihs ect s Sig a re _-Phone Number <br /> - ---62081 <br /> INSTRUCTIONS ON BACK [Correct:0 Incorrect: X � EXAM L E 1 2 3 <br /> ■ White Copy:CalRecycle Yellow Copy:Operator Pink Copy:LEA © ■ <br />