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Waste Tire Survey & Inspection Report Inspection Report Number ■ <br /> CalRecycle State of California <br /> CalRecycle 181 (Rev.10/10) 11 - 1196349 <br /> Dept.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 /> TIPID- Inspection Type(Fill one) <br /> Site Suffix: 1 y y 3 6 0 Routine 0 Re-inspection 0 Referral 0 Observation <br /> Local If Referral,choose referral type(Fill one) <br /> CCAACW <br /> Identifier: >Ckv\. '� 0 CHIP 0 CalRecycle 0 Complaint 0 Educational Visit 0 Other <br /> � <br /> Business or Facility Name 1 Inspected By Inspector <br /> Physical Address <br /> Inspection Date 5- <br /> �A Time In Time Out <br /> Business Rep Title0 AM 4SAM <br /> 2- OPM 0 PM <br /> 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 (Who1CjPTE)',, <br /> 0 Active Passenger Generator 0 Outdoor <br /> 0 0 Closed 0 Altered <br /> GpS Latitude 0 Hauler 0 indoor <br /> 0 0 Inactive 0 Truck <br /> Longitude 0 Planned 0 OTR 0 End-use 0 container <br /> Business Type(Fill all that apply) — <br /> 0 New Tire Dealer 0 Auto Repair 0 Trucking Fleet 0 Government 0 Retreader 0 Dismantler 0 Tire Derived Fuel <br /> 0 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 I A I 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 Date01 <br /> / m <br /> 0 0 14 CCR§18459.1 -Tire Program ID Number from CalRecycle F3 <br /> (Required for NOV or EXT)0 0 14 CCR§18459.2.1 -Submittal of Comprehensive Trip Logs within 90 days C? <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 /> 2 <br /> 0 0 14 CCR§18461 -Manifest System Requirements for Waste Tire End-Use Facilities — <br /> 0 0 14 OCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators I&in compliance-No Violations <br /> 10 1 0 .Other:§ <br /> Comments <br /> /v, <br /> Inspection Form Included: 0 PLICP 12 view —Q-A'Z <br /> Comments Included: Business Rep's Sign Phone Number I pe 9 ure Phone Number <br /> Correct:* Incorrect: q 62081 <br /> 6k� <br /> INSTRUCTIONS ON BACK ve E X A M 2 3 <br /> EWhite Copy:CalRecycle Yellow Copy:Operator Pink Copy:LEA 0 <br />