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0 Waste Tire <br /> Suive & Inspection Re <br /> or0inspection Report Number <br /> CalRecycle10/10) 1255904 <br /> State of California <br /> CalRecycle 181(Rev.10/10) <br /> Survey Form - Page 1 1 - 12 5 5 9 0 4 <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: b U lY Cv 0 Routine 0 Re-inspection 0 Referral 0 Observation <br /> Local ' ,. If Referral,choose referral type(Fill one) <br /> Identifier: 0`, 0 CHP 0 CalRecycle 0 Complaint 0 Educational Visit 0 Other <br /> Businss or Facility Name Inspected By Inspector <br /> ill,iq <br /> Physical Address (� <br /> �l^ Inspection Date 2- 1 C)j T 1 S <br /> Time In Time Out <br /> Business Rep Title0 AM 0 AM <br /> 1 Ci ' -�, V O PMj ( ?_ O 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 0 Passenger 0 Generator 0 O„utdgor <br /> O 0 Closed 0 Altered en <br /> GPS Latitude 0 Hauler 0 Indoor <br /> O Q Inactive Q Truck <br /> Longitude - 0 Planned IS OTR 0 End-Use 0 Container <br /> Business Type(Fill all that apply) <br /> 0 New Tire Dealer 0 Auto Repair 0 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 /> O O Q Notice Of Violation Q 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 / 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 EXT) n <br /> 0 0 14 CCR§18459.3-Retention of Comprehensive Trip Logs for 3 years o <br /> 0 0 14 CCR§18460.2-Manifest System Requirements for Registered Waste Tire Haulers 0 Referred/CalRecycle Enforcement <br /> W <br /> 0 0 14 CCR§18461 -Manifest System Requirements for Waste Tire End-Use Facilities <br /> 0 0 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators In Compliance-No Violations o <br /> 0 0 Other:§ z <br /> Comments �” <br /> `fes 1&rlo,lg V_)lua f IH, <br /> Inspection Form Included: 0 ` 4&e �'L <br /> Comments Included:S <br /> Busi s 's Signature Phone Number Inspector's Comm Phone Number <br /> �( <br /> INSTRUCTIONS ON ACK Correct: Incorrect: X (� NJ jEjXjA�MjPjLjEj 1112 3 62081 <br /> ■ White Copy:CalRecycle Yellow Copy:Operator Pink Copy:LEA © ■ <br />