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Waste Tire Su. vey & Inspection Report Inspection Report Number <br /> CalRec cle State of California — <br /> Y CalRecycle181.(Rev.10/10) Survey Form - Page 1 I1 1230121 <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: LA _ © Routine QRe-inspection Q Referral <br /> Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier: Q CHP Q CalRecycle Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name ' Inspected By Inspector <br /> n 1 <br /> .u.ri. ASI- cr��-� sv� ce, 1 0 <br /> Physiicagddress 3 °I - 1 Es(,6T7 v <br /> Inspection Date <br /> Time In Time Out <br /> BusinessRepTitle �1 O AM O AM <br /> &U, oS 0 ® PM 3 � 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 /> Q Active Q Pasgenger Q Generator Q Outdoor <br /> Cl )) <br /> Cads Latitude Q HaulelF/C� Q Indoor <br /> O Q Inactive Q 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 AI'JdL CuQ,It'iM4w4f)c. <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 <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 Exr� N <br /> a <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 /> W <br /> W <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 In Compliance-No Violations o <br /> Q Q Other:§ <br /> Comments ��,h,U1 1 .� r N <br /> l s <br /> wUe, he 'er - Nk )JA' CA 4i(y) c, n(JUr) <br /> "s C LVtQ 5 Lena <br /> Inspection Form Included: Q ����� <br /> Comments Included: Q J <br /> 7 S <br /> Business Rep' ignature Phone Number Ins tor's Signature ___Phone Number <br /> INSTRUCTIONS ON BACK [Correct:* Incorrect: IEIXIAIM^ E 1112 3 62081 <br /> ■ White Copy:CalRecycle Yellow Copy:Operator Pink Co y:L ® 0 <br />