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Waste Tire Survey & Inspection Report inspection Report Number ■ <br /> CalRecycle State of California <br /> CalRecycle 181(Rev.10/10) 11 - 1230360 <br /> De-pt.of Resources Recycling and Recovery(CalRecycle) Survey Form - Page 1 BLUE OR BLACK INK PEN <br /> Part A-Survey <br /> Business Profile Inspection Details <br /> TPID- Inspection Type(Fill one) <br /> Site Suffix: 3 1 0 Routine 0 Re-inspection 0 Referral 0 Observation <br /> LocalIf Referral,choose referral type(Fill one) <br /> Identifier: Save �Ck,-Cv_t col/vv 111-1 0 CHP 0 CalRecycle 0 Complaint 0 Educational Visit 0 Other <br /> Business or Facility Name Inspected By Inspector <br /> Physical Address <br /> Inspection Date � <br /> G LI <br /> s. (C'J Time In Time Out <br /> Business Rep Title 0 AM 0 AM <br /> ` V _ 3 0 PM I Z G opm <br /> 7 Operational Status Tire Type Business Role Storage Type <br /> (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> Tire Count (Whole/PTE) <br /> ® Active Passenger f) Generator Ile Outdoor <br /> . O 0 Closed Altered <br /> GPS Latitude 0 Hauler Indoor <br /> 0 0 inactive Truck <br /> Longitude 0 Planned OTR 40 End-Use Container <br /> Business Type(Fill all that apply) <br /> 0 New Tire Dealer CD Auto Repair 0 Trucking Fleet 0 Government 0 Retreader 0 Dismantler 0 Tire Derived Fuel <br /> III Used Tire Dealer 0 Auto Body 0 Car Dealer 0 Collection 0 Crumb Rubber <br /> 0 Service Station 0 Hauler 0 Agriculture 0 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 0 Notice Of Violation 0 Extension <br /> 0 0 PRC§42951 -Waste Tire Hauler Registration and Transport of Tires <br /> 0 0 PRC§42953-Contracts with Registered Waste Tire Haulers. Compliance Deadline <br /> 0 0 PRC§42956-Registration/Decal in Vehicle <br /> 0 0 14 CCR§18459-Responsible Entities Complying with Manifesting Requirements Date M / m / m <br /> 0 0 14 CCR§18459.1 -Tire Program ID Number from CalRecycle <br /> (Required for NOV or EX7) <br /> 0 0 14 CCR§18459.2.1 -Submittal of Comprehensive Trip Logs within 90 days <br /> 0 0 14 CCR§18459.3-Retention of Comprehensive Trip Logs for 3 years <br /> 0 0 14 CCR§18460.2-Manifest System Requirements for Registered Waste Tire Haulers 0 Referred/CalRecycle Enforcement <br /> uj <br /> 0 0 14 CCR§18461 -Manifest System Requirements for Waste Tire End-Use Facilities <br /> 0 0 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators (ID in Compliance-No Violations <br /> 0 , 0 Other:§ <br /> Comments <br /> Inspection Form Included. <br /> CkAJ-4_-. 6;o <br /> Comments Included- <br /> Business Rep's Signature Phone Number I p C 0 Si ature Phone Number <br /> 62081 <br /> INSTRUCTIONS ON BACK Correct:* Incorrect: M A2�) E A L <br /> V W <br /> ■ White Copy:CalRecycle Yellow Copy:Operator Pink Cop : ® ■ <br />