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Waste Tire Survey & Inspection Report Inspection Report Number <br /> CalRecycle State of California I 1 - 1229946 <br /> CalRecycle 181(Rev.10/10) Survey Form - Page 1 <br /> Dept of Resources Recycling and Recovery(CalRecycle) <br /> _ BLUE OR BLACK INK PEN <br /> Part A-Survey <br /> Business Profile Inspection Details <br /> TPID- Inspection Type(Fill one) <br /> Site Suffix: I b b 3 —1 V I 00 Routine Q Re-inspection Q Referral Q Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier: V; ,��/ Q CHP Q CalRecycle Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name `7 Inspected By Inspector <br /> PhysicOal Ad ss p`h 2> q Cj V <br /> Inspection Date O Z / I 1 / ' S <br /> Time In Time Out <br /> Business Rep Title 9 hh 0 AM �+ (� SAM <br /> V Q PM -1 l 0 PM <br /> Sex�Y. <br /> w51 \1 \ CL n <br /> Operational Status Tire Type Business Role Storage Type <br /> Tire Cou t (Whole/PTE) (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> Q Active Q Passenger Q Generator Q Outdoor <br /> Latitude O • Closed O Alterg�i /A O Ha lel /yOor <br /> GPS /V <br /> O Q Inactive Q Truck <br /> Longitude - O Planned O OTR O End-Use O Container <br /> Business Type(Fill all that apply) <br /> Q New Tire Dealer Q Auto Repair Q Trucking Fleet O Government Q Retreader Q Dismantler Q Tire Derived Fuel <br /> Q Used Tire Dealer O Auto Body Q Car Dealer Q Collection Q Crumb Rubber / <br /> Q Service Station Q Hauler Q Agriculture Q Shredder I*Other <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 0 Extension <br /> O O 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 /> Q Q 14 CCR§18459.1 -Tire Program ID Number from CalRecycle <br /> (Required for NOV or EXT) <br /> O O 14 CCR§18459.2.1 -Submittal of Comprehensive Trip Logs within 90 days <br /> N <br /> 0 O 14 CCR§18459.3-Retention of Comprehensive Trip Logs for 3 years o <br /> 0 O 14 CCR§18460.2-Manifest System Requirements for Registered Waste Tire Haulers Q Referred/CalRecycle Enforcement <br /> Lu <br /> O O 14 CCR§18461 -Manifest System Requirements for Waste Tire End-Use Facilities - <br /> O O 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators •In Compliance No Violations o <br /> Q O Other:§ <br /> Comments `` QV-, - <br /> L <br /> �s �C t- ' <br /> Inspection Form Included: _` <br /> Comments Included: <br /> z�� Co2`l• 5 Z v .J <br /> Business Rep's Signature Phone Number Inspect s Signature Phone Number <br /> 62081 <br /> INSTRUCTIONS ON BACK [Correct.0 Incorrect: XA 4&) <br /> EXAMPLE 1 2 3 <br /> ■ White Copy:CalRecycle Yellow Copy:Operator Pink Copy:LEA ® ■ <br />