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02 Waste Tire Sur Jey & Inspection Report inspection Report Number <br /> Cal Rec cle State of California <br /> Y CalRecycle 181(Rev.10/10), Survey Form - Page 1 1 1230071 <br /> Dept.of Resources Recycling and Recovery(CalRecycle) <br /> Part A-Survey BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- Inspection� � � - O ` Inspection Type(Fill one) <br /> � <br /> Site Suffix: ` ) 6 I 0 Routine 0 Re-inspection 0 Referral 0 Observation <br /> Local n If Referral,choose referral type(Fill one) <br /> Identifier: ��� J p��v\ CO�� 0 CHP 0 CalRecycle 0 Complaint 0 Educational Visit 0 Other <br /> Business or Facility Name ( Inspected By Inspector <br /> � K_CW'�� 5 Cy 61!5 r T. _C. 2> l d IUl I v <br /> 1 Physical Address <br /> G-1 1 <br /> C� l 5 370 Inspection Date <br /> Time In Time Out <br /> Business Rep Title Al l A Al <br /> 0P I 0P <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 0 Active 0 Passenger 0 Generator 0 Outdoor <br /> O 0 Closed 0 Altered Al M, N/ <br /> GPS Latitude N0 Hauler 0 Indoor <br /> O 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 Other Mor �e (�in <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 <br /> 0 0 0 Notice Of Violation 0 Extension <br /> 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 <br /> 0 0 14 CCR§18459.1 -Tire Program ID Number from CalRecycle <br /> 0 0 14 CCR§18459.2.1 -Submittal of Comprehensive Trip Logs within 90 days (Required for NOV or EXE N <br /> a <br /> 0 0 14 CCR§18459.3-Retention of Comprehensive Trip Logs for 3 years o <br /> 0 0 14 CCR§18460.2-Manifest System Requirements for Registered Waste Tire Haulers 0 Referred/CalRecycle Enforcement <br /> 2 <br /> W <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 In Compliance-No Violations o <br /> 0 0 Other:§ <br /> Comments <br /> q- 0 _ G-S n <br /> Cl�i <br /> Inspection Form Included: 0 */ <br /> Comments Included: 0 <br /> Business Rep's Signature Phone Number Inspect is Signature Phone Number <br /> INSTRUCTIONS ON BACK Correct:0 Incorrect: X I E I X I AlM P JLJEJ 1112T3 62081 <br /> . White Copy:CalRecycle Yellow Copy:Operator Pink Copy:LEA <br />