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Waste Tire Survey & Inspection ReporAnspection Report Number <br /> Cal Rec cle State of California — <br /> Y CalRecycle 181(Rev.10/10) Survey Form - Page 1 11 1245095 <br /> Dept.of Resources Recycling and Recovery(CalRecycle) <br /> part A-Survey BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- - © I Inspection Type(Fill one) <br /> Site Suffix: 4&Routine Q Re-inspection Q Referral Q Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier: �( � WLCI01 Y1 0 O Q CHP Q CalRecycle Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name y Inspected By Inspector <br /> TCr-d -I rsY+ C/ , , - ► 1rv�a��L t� � ry <br /> Physical Address <br /> Inspection Date 1 S <br /> Time In Time Out <br /> Business Rep Title J� 0A1 j O AM <br /> ' V 40 PM / O PM <br /> �-�YL tyle (5 W4U- I`oa"O <br /> d Operational Status Tire Type Business Role Storage Type <br /> Tire Count(Whole/PTE) I (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> ' ® Active Q Passenger 0 Generator •Outdoor CLl <br /> Q Closed Q Altered \ <br /> GPS Latitude Q Hauler Q Indoor <br /> o Q Inactive IS Truck Longitude - Q End-use ® Containe(C <br /> Q Planned Q OTR <br /> Business Type(Fill all that apply) <br /> Q New Tire Dealer Q Auto Repair O 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 f� <br /> Q Service Station Q Hauler Q Agriculture Q Shredder 0 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 <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 /> 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 <br /> in Compliance-No Violations o <br /> Q Q Other:§ - <br /> Comments I2_6 u_f_ U of Akk- -k y--Q— 1 K_ d4_V_ (.%�0� (JVl 4" <br /> U I of .u_f.G 4--.,-- a-LQ <br /> Inspection Form Included: Q <br /> Comments Included: <br /> _ usi s Rep's Signature Phone Number 41npecto`rs�VgZnture Phone Number <br /> INSTRUCTIONS ON BACK Correct:is Incorrect: � � EXAMPLE 1 2 3 62081 <br /> ■ White Copy:CalRecycle Yellow Copy:Operator Pink Copy:LEA <br />