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Waste Tire Su,vey & Inspection Report Inspection Report Number <br /> CalRecycle State of califo is <br /> Y CalRecycle 181(Rev.10/10) Survey Form - Page 1 I1 1177708 <br /> Dept.of Resources Recycling and Recovery(CalRecycle) <br /> Part A- Survey BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- Inspection Type(Fill one) <br /> Site Suffix: l q ,z -2 1 6 Routine 0 Re-inspection 0 Referral 0 Observation <br /> Localc - If Referral,choose referral type(Fill one) <br /> Identifier: JGI VI t-/1� C©(!✓t 0 CHP 0 CalRecycle 0 Complaint 0 Educational Visit 0 Other <br /> Business or Facility Name <br /> Inspected By Inspector <br /> 1 _ <br /> Q azo <br /> Physical Address <br /> Inspection Date <br /> Time In Time Out <br /> Business Rep Title Q AM `` 40 AM <br /> 0 ' -5- G 0P } 1 z QPM <br /> CLAW-41-11 <br /> - Operational Status Tire Type Business Role Storage Type <br /> Tire Count(Whole/PTE) (Fill one only) (FII all that apply) (Fill all that apply) (Fill all that apply) <br /> 1 2 1 0 Active 0 Passenger 0 Generator ® Outdoor <br /> O 0 Closed 0 Altered <br /> GPS Latitude 0 Hauler 0 Indoor <br /> o Q Inactive 10Truck <br /> Longitude - 0 Planned 0 OTR 0 End-Use 0 Container <br /> Business Type(Fill all that apply) <br /> 0 New Tire Dealer 0 Auto Repair ® Trucking Fleet 0 Government 0 Retreader 0 Dismantler 0 Tire Derived Fuel <br /> 0 Used Tire Dealer 0 Auto Body 0 Car Dealer 0 Collection 0 Crumb Rubber <br /> 0 Service Station 0 Hauler 0 Agriculture 0 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 /> 0 0 Q Notice Of Violation 0 Extension <br /> PRC§42951 -Waste Tire Hauler Registration and Transport of Tires <br /> 0 0 PRC§42953-Contracts with Registered Waste Tire Haulers. Compliance Deadline <br /> PRC§42956-Registration/Decal in Vehicle <br /> 0 0 14 CCR§18459-Responsible Entities Complying with Manifesting Requirements Date m / m <br /> 0 0 14 CCR§18459.1 -Tire Program ID Number from CalRecycle <br /> 0 0 14 CCR§18459.2.1 -Submittal of Comprehensive Trip Logs within 90 days (Required for NOV or EXE n <br /> 0 0 14 CCR§18459.3-Retention of Comprehensive Trip Logs for 3 years <br /> 0 <br /> 0 0 14 CCR§18460.2-Manifest System Requirements for Registered Waste Tire Haulers 0 Referred/CalRecycle Enforcement <br /> 0 0 14 CCR§18461 -Manifest System Requirements for Waste Tire End-Use Facilities W <br /> 0 0 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators <br /> In Compliance No Violations o <br /> 0 0 Other:§ - -- -- <br /> z <br /> Comments <br /> Inspection Form Included: Q <br /> Comments Included: ® 6 Z <br /> legusin ss Rep's Signat a Phone Number I p to i ature Phone Number <br /> 62081 <br /> INSTRUCTIONS ON BACK Correct: Incorrect: E A M L 11213 <br /> ■® White Copy:CalRecycle Yellow Copy:Operator Pink Copy: <br />