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"a Waste Tire Sup Bey & Inspection Reporl. Inspection Report Number <br /> CalRecycle State of California I 1 - 1196575 <br /> CalRecycle 181(Rev.10/10) 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� � � t j -7 _ O ' Inspection Type(Fill one) <br /> Site Suffix: "� 0 Routine Q Re-inspection Q Referral Q Observation <br />fLocalIfReferral,choose referral type(Fill one) <br /> Identifier: ®�V CovA Q CHP Q CalRecycle Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name Inspected By Inspector <br /> ':::5- G1�00 Q <br /> Physical Add 3 -1 - Q <br /> Inspection Date � Z / � I � I 3 <br /> Time In Time Out <br /> Business Rep Title � AM O ® AM <br /> O , © QPM 1 ® QPM <br /> �cf'Y\S _ �er. C. <br /> -- -- Operational Status Tire Type Business Role Storage Type <br /> Tire Count (Whole/PTE) r7 (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> L 0 Active Q Passenger 9 Generator ® Outdoor <br /> o Q Closed Q Altered <br /> Cads Latitude Q Hauler Q Indoor <br /> O Q Inactive 40 Truck <br /> Longitude - Q Planned Q OTR O 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 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 /> 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 /> PRC§42956-Registration/Decal in Vehicle <br /> Q Q 14 CCR§18459-Responsible Entities Complying with Manifesting Requirements Date m / m / Ffl <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 EJ(7) N <br /> Q Q 14 CCR§18459.3-Retention of Comprehensive Trip Logs for 3 years o <br /> Q Q 14 CCR§18460.2-Manifest System Requirements for Registered Waste Tire Haulers Q Referred/CalRecycle Enforcement <br /> 2F <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 0 In Compliance-No Violations o <br /> Q Q Other:§ ___ <br /> Comments `�`� <br /> �ov �rQ �aS ,pc3 �\ p �''_M 6,0 nR. CPN <br /> Inspection Form Included: Q aoq 5f� <br /> Comments Included: <br /> si one umber Insp .tors Signature Phone Number <br /> INSTRUCTIONS ON BACK Correct:* Incorrect: " EXAMPLE 1112 3 62081 <br /> White Copy:CalRecycle Yellow Copy:Operator Pink Copy:LEA ® ■ <br />