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2 Waste Tire Su. ✓e & Inspection Repo�lnspection Report Number <br /> CalRecycle State of California Y <br /> - Y CalRecycle 181(Rev.10/10) Survey Form Page 1 11 - 1229969 <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- ' Inspection Type(Fill one) <br /> Site Suffix: 5 f 7 40 Routine Q Re-inspection Q Referral Q Observation <br /> Local 1 If Referral,choose referral type(Fill one) <br /> Identifier: SO�N1 a aV rttJ Q CHP Q CalRecycle Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name 4 777 Inspected By Inspector <br /> Physical Address <br /> CC n ol Inspection Date Q Z Z s S <br /> Time In Time Out <br /> Business Rep Title OAM O AM <br /> `-�- Operational Status Tire type Business Role Storage Type <br /> Tire Count (Whole/PTE) .25 (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> • Active 9 Passenger 9 Generator Q Outdoor <br /> O Q Closed Q Altered <br /> GPS Latitude Q Hauler 10 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 a 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 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 O 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 EXE <br /> Q Q 14 CCR§18459.3-Retention of Comprehensive Trip Logs for 3 years N <br /> F <br /> Q Q 14 CCR§18460.2-Manifest System Requirements for Registered Waste Tire Haulers Q Referred/CalRecycle Enforcement <br /> 2 <br /> Q O 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 loin Compliance-No Violations o <br /> Q Q Other:§ <br /> Comments <br /> -- LIZ) v/l c- cam- C3Vv' er <br /> Inspection Form Included; Q e <br /> Comments Included. GV `� <br /> Business Rep's SignatI4 Phone Number Inspec is Signature Phone Number <br /> INSTRUCTIONS ON BACK lCorrefte Incorrect: X4_V]jEjXjAjMjPjLjEj 1112 3 62081 <br /> White Copy:CalRecycle Yeilow Copy:Operator Pink Copy:LEA <br />