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Waste Tire S-Pvey & Inspection Repo AInspection Report Number <br /> CalRecycle State of California <br /> Y CalRecycle 181(Rev.10/10) Survey Form - Page 1 I1 1230078 <br /> Dept.of Resources Recycling and Recovery(CalRecycle) <br /> Part A-Survey _ BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- � � � � � � � O ' Inspection Type(Fill one) <br /> Site Suffix: 1 0 Routine Q Re-inspection Q Referral Q Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier: �On r;V� C�V,(`Ir/ Q CHP Q CalRecycle Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name V \\ Inspected By Inspector <br /> Physlca res <br /> Ad sC <br /> CA- Inspection Date <br /> Time In Time Out <br /> Business Rep .Title *AM �1 _ AM <br /> PM <br /> ONC"S V 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 /> e Active Q Passenger If Generator QN/�Outdoor <br /> O <br /> GPS Latitude Q Closed Q Altered Q Hauler Q Indoor <br /> 0 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 Other SGti,o��, 5�cti <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 <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) 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 /> 2 <br /> Q Q 14 CCR§18461 -Manifest System Requirements for Waste Tire End-Use Facilities W <br /> Q O 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators In Compliance-No Violations o <br /> Q Q Other:§ <br /> Comments \ ..\� l>Jb.-�✓� 'F-i'C'� 1`��i ��T, (�-'h���� <br /> 63 r\C c►X <br /> lu <br /> Inspection Form Included: Q r:�3 <br /> Comments Included: <br /> Business Rep's Sign re Phone Number InspeeTor's Signature Phone Number <br /> INSTRUCTIONS ON BACK Correct: Incorrect: jEjXjAjMPjLjEj 1 2 3 62081 <br /> White Copy:CalRecycle Yellow Copy:Operator Pink Copy:LEA <br />