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� Waste Tire Sufvey & Inspection Report <br /> inspection Report Number <br /> Cal Rec cle State of California — <br /> Y CalRecycle 181(Rev.10/10) Survey Form - Page 1 I 1 1245339 <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: "� I f 0 Routine -Q Re-inspection Q Referral Q Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier. Gaq ( (0 CQ CHP Q CalRecycle Q Complaint Q Educational Visit Q Other <br /> Business or pFaacility Name c I Inspected By Inspector <br /> 0y-C;V fCL-y 6L su 4 i C,• t+Lvd "-k �J rt f <br /> Physical Address 1I I - `� 1 5 <br /> Inspection Date / / l 5 <br /> /l Time In Time Out <br /> // j� , / i0 AM <br /> Business Rep Titlef V 0 PM I ( PM <br /> �v(sls�� �G�1'l i'�Z Tlrca.rtiS �I/t <br /> Operational Status Tire Type Business Role Storage Type <br /> (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> Tire Count hole PTE) /�/ <br /> • Active Q Passenger 0 Generator Q Out"'dd�o``Cor/r <br /> GPS Latitude O Q Closed Q Altered Q Hauler Q Indoor <br /> O Q Inactive S Truck <br /> Longitude - Q Planned O OTR Q End-Use Q Container <br /> Business Type(Fill all that apply) <br /> Q New Tire Dealer Q Auto Repair ® 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 QQ 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 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 /> 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 In Compliance-No Violations o <br /> Q Q Other:§ z <br /> r i <br /> Comments CNt;� d-ah <br /> � - O'i'l_ N <br /> V►C��C�=�n�. GI'��2 o n <br /> Inspection Form Included: Q <br /> Comments Included:0 <br /> Business Rep ture Phone Number Inspector's Signature Phone Number <br /> INSTRUCTIONS ON BACK Correct:0 Incorrect: EXAMPLE111273 62081 <br /> ■ White Copy:CalRecycle Yellow Copy:Operator Pink Copy:LEA ® 0 <br />