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Waste Tire Sup vey & Inspection Report inspection Report Number ■ <br /> Cal Rec cle state of California — <br /> Y CalRecycle 181(Rev.10/10) <br /> Survey Form - Page 1 11 1230234 <br /> Recycle) <br /> Dept of Resources Recycling and Recovery(Cal <br /> Part A-Survev BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- D i _ Q I Inspection Type(Fill one) <br /> Site Suffix: Q Routine Re-inspection Q Referral Q Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier: �(� 1 V�r\ uri Q CHP Q CalRecycle Q Complaint Q Educational Visit Q Other <br /> Business or FacilityName l� <br /> Inspected By Inspector <br /> Physical Address <br /> - -AA �- Tu- <br /> � Inspection Date t ``� 'Z <br /> Time In TimeOut <br /> Business Rep Title O AM O AM <br /> d PM PM <br /> IV h Q, <br /> - Operational Status The Type Business Role Storage Type <br /> Tire Count (Whole/PTE) 3o <br /> (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> iActive Q Passenger ! Generator 10 Outdoor <br /> 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 Q Container <br /> Business Type(Fill all that apply) <br /> New Tire Dealer Q Auto Repair Q Trud&V Fleet Q Government Q Retreader Q Dismantler Q Tire Derived Fuel <br /> l Used Tire Dealer Q Auto Body Q Car Dealer O Collection Q Crumb Rubber <br /> Service Station Q Hauler Q Agria ilture 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 REQUL9WENTS <br /> Q Notice Of Violation Q Extension <br /> Q Q <br /> PRC§42951 -Waste Tire Hauler Registration and Trswoort of Tires <br /> Q Q PRC§42953-Contracts with Registered Waste Tire HaAers. Compliance Deadline <br /> PRC§42956-Registration/Decal in Vehicle <br /> Q Q 14 CCR§18459-Responsible Entities Complying with Manifesting Requirements Date M / M / FT <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 EXE 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 <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 40 In Compliance-No Violations o <br /> Q L Q Other:§ <br /> Comments '9�.e-�hs�c<�p� �bvt•e 6�n, ��S �!�� �—� '1�I�V��W�-S ��T�-y= C <br /> t <br /> 1."C's -mac r <br /> Inspection Form Included: Q <br /> Comments Included: Q <br /> Busi ss Rep's Signature Phone Number Inspe or's Signature Phone Number <br /> INSTRUCTIONS ON BACK Correct: Incorrect: E I X I A I M I P I L E 1 2 3 62081 <br /> ■ White Copy:CalRecycle Yellow Copy:Operator Pink Copy:LEA <br />