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Waste Tire Sulvey & Inspection Report Inspection Report Number ■ <br /> CalRec cle State of California <br /> Y CalRecycle 181(Rev.10/10). Survey Form - Page 1 , 11 1230140 <br /> Dept.of Resources Recycling and Recovery(CalRecycle) <br /> Part A - Survey _ BLUE OR BLACK INK PEN <br /> I Business Profile Inspection Details <br /> TPID- Inspection <br /> Inspection Type(Fill one) <br /> Site Suffix: } $ L C 1 0 Routine Q Re-inspection Q Referral Q Observation <br /> Local , If Referral,choose referral type(Fill one) <br /> Identifier: S 0 CHP Q CalRecycle Q Complaint Q Educational Visit Q Other <br /> Business or FII cility Name Inspected By Inspector <br /> 11� S Mbb4cl 04 SU,�-O _ f / <br /> Physical Address 3 �1 ` 01 li s LoTTb <br /> C� /1. �O Inspection Date r n"L� Time In Time Outl <br /> Business Rep Title 0 AM AM <br /> I Q l/1�nfl' V 0 Q PM + V r� QPM <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 /> 0 Active O Passenger Generator Q Outdoor <br /> O Q Closed Q Altered <br /> GPS Latitude Q Hauler Q Indoor <br /> O Q Inactive Q Truck <br /> Longitude - O Planned A OTR O End-Use O Container <br /> Business Type(Fill all that apply) rnr <br /> Q New Tire Dealer O 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 O Collection Q Crumb Rubber J <br /> Q Service Station Q Hauler O Agriculture Q Shredder 0 Other r0o ,-F,r <br /> Part B - Inspection of Waste Tire Dealer, Generator, Hauler and End-Use Facility ENFORCEMENT STATUS <br /> V I A HAULING AND MANIFEST REQUIREMENTS <br /> Q Notice Of Violation Q Extension <br /> O O <br /> PRC§42951 -Waste Tire Hauler Registration and Transport of Tires <br /> O O PRC§42953-Contracts with Registered Waste Tire Haulers. Compliance Deadline <br /> O O PRC§42956-Registration/Decal in Vehicle <br /> O O 14 CCR§18459-Responsible Entities Complying with Manifesting Requirements Date m / m / m <br /> 0 Q 14 CCR§18459.1 -Tire Program ID Number from CalRecycle <br /> O 0 14 CCR§18459.2.1 -Submittal of Comprehensive Trip Logs within 90 days (Required for NOV or EXE N <br /> O 0 14 CCR§18459.3-Retention of Comprehensive Trip Logs for 3 years <br /> O O 14 CCR§18460.2-Manifest System Requirements for Registered Waste Tire Haulers Q Referred/CalRecycle Enforcement <br /> Q O 14 CCR§18461 -Manifest System Requirements for Waste Tire End-Use Facilities W <br /> O O 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators ®In Compliance-No Violations o <br /> Q Q Other:§ tl l l <br /> Comments 1' 1 a 1 l it1 f/� - 1�5 7S <br /> o� lj� fil W C4 eGl <br /> lfiyi�l � Ns oIr�,llteln- <br /> Inspection Form Included: Q O - <br /> Comments Included: ® �� -`z jj <br /> BPness Rep's Signature Phone Number Insp tor's Signature Pone Number <br /> 62081 <br /> INSTRUCTIONS ON BACK [Correct,0 Incorrect: E X A L 1 2 3 <br /> ■ White Copy:CalRecycle Yellow Copy:Operator Pink Co y: © ■ <br />