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Waste Tire Survey & Inspection Repo <br /> CalRecycle y p p _ <br /> State of California <br /> Y CalRecycle 181(Rev.y(CalRecycle) Survey <br /> Survey Form - Page 1 1 1245293 <br /> Dept of Resources Recycling and Recovery(CalRecycle) <br /> Part A-Survey BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- l' Inspection Type(Fill one) <br /> Site Suffix: ` 5 5 l Z 1 Z (� ' 0 Routine Q Re-inspection Q Referral Q Observation <br /> Local ` If Referral,choose referral type(Fill one) <br /> Identifier: S�r �0 �y v C�J��+,/ Q CHP Q CalRecycle Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name Inspected By Inspector <br /> Physic�al�ddres� dC� 1 M'� ` v <br /> I 7 k-v\ a e <br /> G Inspection Date <br /> -c,r•G1n Cc�w..p <br /> ` Time In Time Out <br /> Business Rep Title O AM O AM <br /> 2— ' 0 QPM 2- PM <br /> OWE � « r' Operational Status Tire Type Business Role Storage Type <br /> Tire Count (Whole/PTE) 1 I (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> Active Q Passenger 0 Generator • Outdoor <br /> Q Closed O Altered <br /> GPS Latitude Q Hauler Indoor <br /> O Q Inactive 40 Truck <br /> Longitude - O Planned Q OTR O End-Use O Container <br /> Business Type(Fill all that apply) <br /> Q New Tire Dealer Q Auto Repair © Trucking Fleet Q Government Q Retreader Q Dismantler Q Tire Derived Fuel <br /> Q 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 <br /> Q Notice Of Violation Q Extension <br /> O O <br /> PRC§42951 -Waste Tire Hauler Registration and Transport of Tires <br /> O O PRC§42953-Contracts with Registered Waste Tire Haulers. Compliance Deadline <br /> PRC§42956-Registration/Decal in Vehicle <br /> O 0 14 CCR§18459-Responsible Entities Complying with Manifesting Requirements Date m / m / m <br /> O O 14 CCR§18459.1 -Tire Program ID Number from CalRecycle <br /> O O 14 CCR§18459.2.1 -Submittal of Comprehensive Trip Logs within 90 days (Required for NOV or EXE <br /> O O 14 CCR§18459.3-Retention of Comprehensive Trip Logs for 3 years <br /> 0 <br /> O O 14 CCR§18460.2-Manifest System Requirements for Registered Waste Tire Haulers Q Referred/CalRecycle Enforcement <br /> O O 14 CCR§18461 -Manifest System Requirements for Waste Tire End-Use Facilities w <br /> O O 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators •In Compliance-No Violations o <br /> Q O Other:§ <br /> Comments ^ � r �rQ <br /> Inspection Form Included: Q Q <br /> Comments Included: I - (o')�3y-1906 <br /> Busin ss ep's Signature Phone Number Inspe toy's Signature Phone Number <br /> INSTRUCTIONS ON BACK �Correct:0 Incorrect: E X A M P L E 1 62081 2 3 <br /> ■ White Copy:CalRecycle Yellow Copy:Operator Pink Copy:LFA, © 0 <br />