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Waste Tire Survey & Inspection Report Inspection Report Number ■ <br /> CalRecycle State of California 0) 1226366 <br /> CalRecycle 181(Rev.10/1 <br /> Dept.of Resources Recycling and Recovery(CalRecycle) BLUE <br /> 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: 3 0 Routine 0 Re-inspection 0 Referral 0 Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier: o 0 CHIP 0 CalRecycle 0 Complaint 0 Educational Visit 0 Other <br /> Business or Facility Name Inspected By Inspector <br /> Ar ()Aau 0r\ 3 lT <br /> Physical idd%rs <br /> Inspection Date <br /> On (A Time In Time Out <br /> Business Rep Title 0 AM ,S 0 AM <br /> D 0 0 PM PM <br /> 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) a. 0 Active 0 Passenger 0 Generator 0 Outdoor <br /> GPS Latitude 0 0 Closed 0 Altered 0 Hauler ® Indoor <br /> 0 0 inactive ® Truck 0 End-Use 0 Container <br /> Longitude 0 Planned 0 OTR <br /> Business Type(Fill all that apply) <br /> Q New Tire Dealer Q Auto Repair 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 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 Date / M <br /> 0 0 14 CCR§18459.1 -Tire Program ID Number from CalRecycle <br /> (Required for NOV or EXT) <br /> N <br /> 0 0 14 CCR§18459.2.1 -Submittal of Comprehensive Trip Logs within 90 days <br /> 0 10 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 <br /> In Compliance-No Violations <br /> 0 0 Other:§ <br /> o 1� I:, <br /> Comments <br /> z I1 <br /> ala nz <br /> SQ, C SA -5 <br /> Inspection Form Included: 0 <br /> 'Ihnone N"umbner <br /> Comments Included: Business Rep's Signature Phone Number Insp or's Signature <br /> Incorrect: 7V lz�. V EXAM L 1 2 3 62081 <br /> INSTRUCTIONS ON BACK Correct:1011 VN 7w <br /> MWhite Copy:CalRecycle Yellow Copy:operator Pink Co y: <br />