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Waste Tire Su. ✓ey & Inspection ReportOnspection Report Number ■ <br /> State of California <br /> CalRecycle I 1 - 1242131 <br /> CalRecycle 181(Rev.10/10) <br /> (Ca[ Survey Form - Page 1 <br /> Dept.of Resources Recycling and Recovery(CalRecycle) <br /> 'art A-Survey BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- _ Inspection Type(Fill one) <br /> Site Suffix: i Routine Q Re-inspection Q Referral Q Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier: CHP c <br /> O�,V� �G(il.Q t!\Yl �V t/�,� Q Q CalRecycle le Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name Y Inspected By Inspector <br /> ?C CA,\ �. Gd��� e�.����LAIC- <br /> Physical Address <br /> I I gin <br /> Inspection Date O � / Z <br /> �u trt f Time In Time Out <br /> Business Rep Title� � FM AM <br /> � � -"� PM <br /> Operational Status Tire Type Business Role Storage Type <br /> Tire Count (Whole/PTE) (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> I* Active Q Passenger • Generator <br /> Q Outdoor <br /> O Q Closed Q Altered N A- <br /> G Latitude Q Hauler Q Indoor <br /> 0 Q Inactive • Truck <br /> Longitude - Q Planned 46 OTR Q End-Use Q Container <br /> Business Type(Fill all that apply) <br /> Q New Tire Dealer Q 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 S 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 Q PRC§42951 -Waste Tire Hauler Registration and Transport of Tires Q Notice Of Violation Q Extension <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 o <br /> Q Q 14 CCR§18459.2.1 -Submittal of Comprehensive Trip Logs within 90 days (Required for NOV or E)CT) N <br /> Q Q 14 CCR§18459.3-Retention of Comprehensive Trip Logs for 3 years <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 In Compliance-No Violations o <br /> Q Q Other:§ <br /> Comments,fl- <br /> YA��v�P l��� ��d't t���-�c2� v�P a^ `C1n�S 1�•2 ,� <br /> y v`�`\�\Q��1y cIY�S (�C- �C P� �� Llc�l►�C'e('Y� <br /> Inspection Form Included: Q i`-- v 3 3 <br /> Comments Included: e 4117-3 -/%G� --/�� <br /> Business Rep's Signature Phone Number Inspec or's Signature Phone Number <br /> �-,( 62081 <br /> INSTRUCTIONS ON BACK Correct: Incorrect: �J EXAMPLE 1 2 3 <br /> ■ White Copy:CalRecycle Yellow Copy:Operator Pink Copy:LEA ■ <br />