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Waste Tire Su,ve & Inspection ReporlOnspection Report Number <br /> CalRecycle State of California Y — <br /> CalRecycle 181(Rev.10/10) Survey Form - Page 1 I1 1242156 <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 Type(Fill one) <br /> Site Suffix: 1 Q Routine Q Re-inspection Q Referral Q Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier: �� / ��-f�.�/��11 � '" i . T1f Q CHP Q CalRecycle Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name / Inspected By Inspector <br /> Physical Address A,6 /S jJ-A <br /> fInspection Date <br /> Time In Time Out <br /> Business Rep Title ® AM , (21 AM <br /> 0 PM ( l C/ C) 0 PM <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 /> ® Active ® Passenger ® Generator 0 Outdoor <br /> Q Closed Q Altered <br /> GPS Latitude Q Hauler Q Indoor <br /> 0 Q Inactive Q Truck <br /> Longitude - Q Planned Q OTR Q End-Use Q Container <br /> Business Type(Fill all that apply) <br /> New Tire Dealer Q Auto Repair Q Trucking Fleet Q Government Q Retreader Q Dismantler Q Tire Derived Fuel <br /> Q Used Tire Dealer Q Auto Body ® 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 I HAULING AND MANIFEST REQUIREMENTS <br /> Q Q PR - Q Notice Of Violation Q Extension <br /> C§42951 Waste Tire Hauler Registration and Transport of Tires <br /> Q Q PRC§42953-Contracts with Registered Waste Tire Haulers. Compliance Deadline <br /> PRC§42956-Registration/Decal in Vehicle <br /> Q Q 14 CCR§18459-Responsible Entities Complying with Manifesting Requirements Date m <br /> Q Q 14 CCR§18459.1 -Tire Program ID Number from CalRecycle ' <br /> Q Q 14 CCR§18459.2.1 -Submittal of Comprehensive Trip Logs within 90 days (Required for NOV or EXn N <br /> a <br /> N <br /> Q Q 14 CCR§18459.3-Retention of Comprehensive Trip Logs for 3 years <br /> Q Q 14 CCR§18460.2-Manifest System Requirements for Registered Waste Tire Haulers Q Referred/CalRecycle Enforcement <br /> Q Q 14 CCR§18461 -Manifest System Requirements for Waste Tire End-Use Facilities w <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 /> e- <br /> 1 <br /> Inspection Form Included: Q J /' <br /> Comments Included: <br /> Busmess Rep's Signature Phone Number 1 s c or's i ature Phone Number <br /> v <br /> I 1 11 11 <br /> INSTRUCTIONS ON BACK Correct: Incorrect: NK ® 62081 <br /> � EXAM 1 2 3 <br /> ■ White Copy:CalRecycle Yellow Copy:Operator Pink Cody: <br />