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Waste Tire Survey & Inspection Report Inspection Report Number ■ <br /> Cal Rec cle state of California — <br /> Y CalRecycle 181(Rev.10110) Survey Form - Page 1 1 1226216 <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- __7 <br /> 7 Inspection Type(Fill one) <br /> Site Suffix: 3 5 ` �-1 ® Routine Q Re-inspection Q Referral Q Observation <br /> Local } If Referral,choose referral type(Fill one) <br /> Identifier: �t �-fi�� ( Q CHP Q CalRecycle Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name Inspected By Inspector <br /> Physical Address <br /> 31�D Avg Cen-v- CN-e- ic,- <br /> Inspection Date ! / LR '� / 1 Z <br /> ���� Time In Time Out <br /> Business Rep / Title ® AM ®AM <br /> �]cG Ac m Ire, r7 6� I © o O PM ( 5 QPM <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 /> r ® Active ® Passenger ® Generator Q Outdoor <br /> Q Closed Q Altered <br /> GPS Latitude Q Hauler Q Indoor <br /> O Q Inactive Q Truck <br /> Longitude - Q Planned Q OTR Q End-Use ® Container <br /> Business Type(Fill all that apply) <br /> Q 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 HAULING AND MANIFEST REQUIREMENTS <br /> Q Notice Of Violation Q Extension <br /> Q Q <br /> 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 <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 EX7) N <br /> a <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 /> Uj <br /> W <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 401 18462 Compliance No Violations o <br /> Q Q Other:§ <br /> Comments <br /> Inspection Form Included: OIi <br /> Cornments Included: <br /> Business s Signature Phone Number ec g at Phone Number <br /> 62081 <br /> INSTRUCTIONS ON BACK Correct:* Incorrect: I E I X A I L 1 2 3 <br /> ■ White Copy:CalRecycle Yellow Copy:Operator Pink Cop -L © ■ <br />