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Waste Tire S,. vey & Inspection Repor, Inspection Report Number ■ <br /> Cal Rec cle State of California <br /> Y CalRecycle 181(Rev.10/10) Survey Form - Page 1 I1 -1176413 <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 Ll 3 1 y -5 5 U 1 ®Routine Q Re-inspection Q Referral Q Observation <br /> Local If Referral,choose referral type(Fill one) <br /> ` VN �o�L Q CHP Q CalRecycle Q Complaint Q Educational Visit Q Other <br /> Identifier: �Ck!A <br /> Business or Facility Name 4 Inspected By Inspector <br /> t�vc�� l �o,motr = oy :�Z�� It(l C� - l © l �4l f ,� Acv m bpi <br /> Physics Add ss <br /> /�35 L, L vv 13 r✓ /-�-��- <br /> - Inspection Date <br /> �� `"}��'gyp C�� ( J �� Time In Time Out l <br /> Business Rep Title 1 0 AM ^� 0 AM <br /> PM X ® PM <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(Whole/PTE) <br /> Q Active ® Passenger ® Generator ® Outdoor <br /> ® Closed Q Altered <br /> GPS Latitude Q Hauler Q Indoor <br /> 0 Q Inactive Q Truck <br /> Longitude - Q Planned Q OTR Q End-Use Q Container <br /> I Business Type(Fill all that apply) <br /> Q New Tire Dealer ® Auto Repair Q Trucking Fleet Q Government Q Retreader Q Dismantler Q Tire Derived Fuel <br /> Q Used Tire Dealer (C) Auto Body Q Car Dealer Q Collection Q Crumb Rubber <br /> Q Service Station Q Hauler Q Agriculture Q Shredder Q Other <br /> I <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 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 N <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 EXT) <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 /> LU <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 /> CommentsThe- <br /> - <br /> �caLt�. IYLS�P" 2rY1 nG�fGYy►�rc <br /> \ J ti(1YI.C\ �[.,_��'1V1C� n�--� IZ L? .f��Yg�� �C'-►'t'.� r+ h's�av -,�Sr.r <br /> o►�.a,,br°,. ►°�u�m e nc� TP�� � 1�l3'7'-�.�,�` ��10-��c-� - <br /> Inspection Form Included: Q <br /> Comments Included: Q - —— - - `� �� <br /> Business Rep's Signature Phone Number s forengnqtairp Phone Number <br /> 62081 <br /> INSTRUCTIONS ON BACK Correct:0 Incorrect: g I E X A M P I L I E I 1 i 12131 <br /> ■ White Copy:CalRecycle Yellow Copy:Operator Pink Copy:LEA ■ <br />