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Oa Waste Tire St..vey & Inspection Repor%6 Inspection Report Number <br /> CalRecycle State of California _ I 1 - 12 2 6 3 7 3 <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- r� p Inspection Type(Fill one) <br /> Site Suffix: ( C./ C2 J d l ® Routine Q Re-inspection Q Referral Q Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier: ��✓� �c✓CC,� `�� GU Q CHP Q CalRecycle Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name Inspected By Inspector <br /> Physical Address <br /> l Inspection Date / 3 <br /> 6A 1`5J- L5 Time In Time Out <br /> Business Rep Title 8 AM 12) AM <br /> • o 5' Q PM / 3 Q 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 /> 7 <br /> Tire Count(Whole/PTE) , ® Active Q Passenger ® Generator Q Outdoor <br /> PS Latitude 0 Q Closed Q Altered Q Hauler ® Indoor <br /> G <br /> Q Inactive ® 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 ® 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 Q Other <br /> Part B - Inspection of Waste Tire Dealer, Generator, Hauler and End-Use Facility ENFORCEMENT STATUS <br /> V A HAULING AND MANIFEST REQUIREMENTS Q Notice Of Violation Q Extension <br /> Q Q PRC§42951 -Waste Tire Hauler Registration and Transport of Tires <br /> Q Q PRC§42953-Contracts with Registered Waste Tire Haulers. Compliance Deadline <br /> Q Q PRC§42956-Registration/Decal in Vehicle <br /> Q Q 14 CCR§18459-Responsible Entities Complying with Manifesting Requirements Date m / m m a <br /> Q Q 14 CCR§18459.1 -Tire Program ID Number from CalRecycle <br /> (Required for NOV or EXT) <br /> Q Q N <br /> 14 CCR§18459.2.1 -Submittal of Comprehensive Trip Logs within 90 days <br /> Q Q 14 CCR§18459.3-Retention of Comprehensive Trip Logs for 3 years o <br /> Q Q Q Referred/CalRecycle Enforcement <br /> 14 CCR§18460.2-Manifest System Requirements for Registered Waste Tire Haulers f <br /> Lu <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 / <br /> N <br /> Inspection Form Included: Q � v <br /> Comments Included: <br /> Business Rep's Signa ure one Number r'_ gnature Phone Number <br /> 62081 <br /> INSTRUCTIONS ON BACK Correct:* Incorrect: l �W Vi E X AIC E 1 2 3 ■ <br /> ■ White Copy:CalRecycle Yellow Copy:Operator Pink C p ' EA <br />