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& <br /> 02 Waste Tire Survey & Inspection Report inspection Report Number <br /> State of California <br /> CalRecycle CalRecycle 181(Rev.10/10) 11 - 1245247 <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 /> TPID- Inspection Type(Fill one) <br /> Site Suffix: 1 Q Q Z V I 0 Routine 0 Re-inspection 0 Referral 0 Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier: <br /> IA 0 CHP 0 CalRecycle 0 Complaint 0 Educational Visit 0 Other <br /> Business or Facility Name /WKmInspected By Inspector <br /> W-y-, fid, s ) <br /> Physical Address <br /> (0 t>tLrr l;5o DrilZ/ Inspection Date Is— <br /> CA— Time In Time Out <br /> Business Rep Title 0 AM 0 AM <br /> 40 PM 0 PM <br /> _6bk cr, OAV/V — age e <br /> p <br /> p ly) <br /> Storage <br /> Type 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(Whole/PTE) 46 Generator Outdoor <br /> Active 0 Passenger <br /> GPS Latitude 0 0 Closed 0 Altered 0 Hauler ® Indoor <br /> 0 0 Inactive 0 Truck 0 End-Use 0 Container <br /> Longitude 0 Planned 0 OTR <br /> Business Type(Fill all that apply) 0 Tire Derived Fuel <br /> 0 New Tire Dealer a Auto Repair 0 Trucking Fleet 0 Government 0 Retreader 0 Dismantler <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 A 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 Datem / M <br /> 0 0 14 CCR§18459.1 -Tire Program ID Number from CalRecycle <br /> (Required for NOV or EX7) <br /> 0 0 14 CCR§18459.2.1 -Submittal of Comprehensive Trip Logs within 90 days <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 /> 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 <br /> 010 Other:§ <br /> Comments UN <br /> AAS al-A- <br /> Inspection Form lncluded: og 7ol 4a -2 <br /> Comments Included: 40 Business s Signature Phone Number Ins ect s Signature Phone Number <br /> Xz �� q 62081 <br /> INSTRUCTIONS ON BACK Correct:0 incorrect: EXAMPLE 111213 ■ <br /> ■ White Copy:CalRecycle Yellow Copy:Operator Pink Copy:LEA <br />