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Waste Tire Su,vey & Inspection Report Inspection Report Number ■ <br /> cle State of California <br /> CalRecycle CalRecycle 181(Rev.10/10) Survey Form page 1 I1 - 1177817 <br /> Dept of Resources Recycling and Recovery(CalRecycle) <br /> Part A-Survey BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- ii Inspection Type(Fill one) <br /> Site Suffix: L 5 3 S O Q Routine ® Re-inspection Q Referral Q Observation <br /> Local k If Referral,choose referral type(Fill one) <br /> Identifier: n J d CO��l Q CHP Q CalRecycle Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name <br /> Inspected By Inspector <br /> (� "�� C/wrC'ss z�C'_ <br /> Physical Address (- <br /> �n �� c (c�n�u �• <br /> Inspection Date <br /> �� Time In Time Out <br /> Business Rep Title OAM /� O � PM <br /> O AM <br /> ' 3 v QPM � V <br /> k O,� �e 3� �b�J 5' vis Or <br /> -- -- Operational Status Tire Type Business Role Storage Type <br /> Tire Count (Whole/PTE) 3 5 V <br /> T (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> ® Active • Passenger ® Generator ® Outdoor <br /> O 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 /> New Tire Dealer Q Auto Repair Q Trucking Fleet Q Government Q Retreader Q Dismantler Q Tire Derived Fuel <br /> ® Used Tire Dealer Q Auto Body Q Car Dealer Q Collection Q Crumb Rubber <br /> Service Station Q Hauler Q Agriculture Q Shredder Q 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 N <br /> Q Q 14 CCR§18459.2.1 -Submittal of Comprehensive Trip Logs within 90 days (Required for NOV or EXT) 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 /> Q Q 14 CCR§18461 -Manifest System Requirements for Waste Tire End-Use Facilities W <br /> Q Q 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators ®In Compliance-No Violations o <br /> Q 1 Q Other:§ <br /> Comments A O LA 0_15 44.1^ ` Un 11 j�3 >��� a ,_Aj&N 111A <br /> del <br /> Inspection Form Included: _7�) — <br /> Comments Included: <br /> nature Phone Number lr spec s Signature Phone Number <br /> INSTRUCTIONS ON BACK I Correct:0 Incorrect: 7X77� NJ E X I A I M P I L I E 1 2 3 62081 <br /> White Copy:CalRecycle Yellow Copy:Operator Pink Copy:LEA <br />