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Waste Tire Su,vey & Inspection Repor ., Inspection Report Number <br /> CalRec cle State of California <br /> Y CalRecycle 181(Rev.10/10) Survey Form - Page 1 11 1245298 <br /> Dept of Resources Recycling and Recovery(CalRecycle) <br /> Part A -Survey BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- ` j, Ca ` -{� Inspection Type(Fill one) <br /> Site Suffix: t 1J/ I L / 0 Routine Q Re-inspection Q Referral Q Observation <br /> Local 5 � If Referral,choose referral type(Fill one) <br /> Identifier: �L.LJ� �tQ CHP Q CalRecycle Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name Inspected By Inspector <br /> Physical Address <br /> l ,�,� Inspection Date <br /> �� 15-203- <br /> 5 � �[� <br /> Time In Time Out <br /> Bu iness Rep Title C 0 AM r6 A` 0 AM <br /> V QPM QPM <br /> 1_ v l _tb� <br /> Operational Status Tire Type Business Role Storage Type <br /> Tire Count ( hot /PTE) /, (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> 1 ((� 0 Active Passenger 0 Generator 0 Outdoor <br /> 0 Q Closed Q Altered <br /> GPS Latitude Q Hauler Q Indoor <br /> 0 Q Inactive Q Truck <br /> Longitude - Q Planned Q OTR 0 End-Use Q Container <br /> Business Type(Fill all that apply) <br /> New Tire Dealer 0 Auto Repair Q Trucking Fleet Q Government Q Retreader Q Dismantler Q Tire Derived Fuel <br /> 0 Used Tire Dealer Q Auto Body Q Car Dealer 0 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 � Extension <br /> O O <br /> PRC§42951 -Waste Tire Hauler Registration and Transport of Tires <br /> 0 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 O 14 CCR§18459.1 -Tire Program ID Number from CalRecycle <br /> O O 14 CCR§18459.2.1 -Submittal of Comprehensive Trip Logs within 90 days (Required for NOV or EXE <br /> O 0 14 CCR§18459.3-Retention of Comprehensive Trip Logs for 3 years <br /> 0 <br /> O Q 14 CCR§18460.2-Manifest System Requirements for Registered Waste Tire Haulers Q Referred/CalRecycle Enforcement <br /> O Q 14 CCR§18461 -Manifest System Requirements for Waste Tire End-Use Facilities W <br /> O Q 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators ®In Compliance-No Violations o <br /> O O Other:§ <br /> CommentsI �� --�� G 1�> .11� Y7 <br /> Aoma— <br /> Vio- <br /> Inspection Form�nc <br /> ncluded: Q llJ�l � <br /> Comments luded: zo <br /> C <br /> Business Rep's Signature Phone Number nspe ors Ig Phone Num er <br /> INSTRUCTIONS ON BACK Correct: Incorrect: N NJ E X A M P L E 1 2 3 62081 <br /> ® White Copy:CalRecycle Yellow Copy:Operator Pink Copy:LEA <br />