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Waste Tire Survey & Inspection Report -inspection Report Nurnber <br /> CalRecycle State of California I 1 - 1226384. <br /> CalRecycle 181(Rev.10/10) Survey Form - Page 1 <br /> Dept.of Resources Recycling and Recovery(CalRecycle) BLUE OR BLACK INK PEN <br /> Part A-Survey - <br /> Business Profile Inspection Details <br /> TPID- Inspection type(Fill one) <br /> Site Suffix: — 1 ' ® Routine Q Re-inspection Q Referral Q Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier: �� Sexes� '� �Ul/l��� Q CHP Q CalRecycle Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name Inspected By Inspector <br /> Physical Address v L <br /> Inspection Date <br /> CA (5�4 0 Time In Time Out <br /> Title ® AM ®AM <br /> Business Rep / © / a 0 PM '5_ G O PM <br /> Operational Status Tire Type Business Role Storage Type <br /> - - —.. <br /> (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> Tire Count (Whole/PTE) <br /> ® Active ® Passenger ® Generator Q 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 �® Container <br /> Business Type(Fill all that apply) - ------- <br /> ® New Tire Dealer Q Auto Repair p Trucking Fleet Q Government p Retreader Q Dismantler Q Tire Derived Fuel <br /> (1) 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 / <br /> Q Q 14 CCR§18459.1 -Tire Program ID Number from CalRecycle <br /> — (Required for NOV or EXE - — N <br /> Q Q <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 14 CCR§18460.2-Manifest System Requirements for Registered Waste Tire Haulers Q Referred/CalRecycle Enforcement <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 In Compliance No Violations o <br /> Q Q Other:§ - --- <br /> 6 <br /> Comments <br /> 67 <br /> - V <br /> Inspection Form Included: Q (77.,��() <br /> Comments Included: <br /> Usines Rep's Signature Phone Number fn &4re Phone Number <br /> • meq 62081 <br /> INSTRUCTIONS ON BACK Correct: Incorrect: (� �/ E X A M P E 1 2 3 ■ <br /> ■ &A <br /> White Copy:CalRecycle Yellow Copy:operator Pink Copy: <br />