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2 Waste Tire Suf e & Inspection Report Inspection Report Number <br /> CalRecycle y <br /> State of California <br /> CalRecycle 181(Rev.10/10) Survey Form - Page 1 1 - 1245324 <br /> Dept.of Resources Recycling and Recovery(CalRecycle) <br /> part A-SurveyBLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- Inspection Type(Fill one) <br /> Site Suffix: 0 Routine Q Re-inspection Q Referral Q Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier: I/1 S(,(�[(of CCLL-vJ\ Q CHP Q CalRecycle Q Complaint Q Educational Visit Q Other <br /> Burs�in'ess or Facility Name v) Inspected By Inspector <br /> A <br /> Physical Address <br /> Inspection Date / 7 <br /> �ktc� C< - `�szvtn <br /> Time In Time Out <br /> Business Rep Title ( O AM 7 O AM <br /> L. I S A PM ' `- a 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 /> Active Q Passenger 0 Generator Q Outdoor <br /> O Q Closed Q Altered a— <br /> GPS Latitude Q Hauler Q Indoor <br /> O Q Inactive 0 Truck <br /> Longitude - Q Planned Q 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 ® OtherQ. � VvllD^ <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 /> Q Q PRC§42956-Registration/Decal in Vehicle <br /> Q Q 14 CCR§18459-Responsible Entities Complying with Manifesting Requirements Date <br /> Q Q 14 CCR§18459.1 -Tire Program ID Number from CalRecycle Ln <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 <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 In Compliance-No Violations o <br /> Q Q Other:§ <br /> Comments / <br /> (p.6- <br /> !/L�-j J/I U CC¢-tc;C�un <br /> Inspection Form Included: Q L,q �l/ <br /> Comments Included: <br /> Business Rep's Signature Phone Number Inspect is Signaturej4 Phone Number <br /> INSTRUCTIONS ON BACK Correct: Incorrect: � Q E X A M P LIE 1 213 62081 <br /> White Copy:CalRecycle Yellow Copy:Operator Pink Copy:LEA <br />