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Waste Tire Survey & Inspection Report Inspection Report Number ■ <br /> cle State of California <br /> CalRecycle <br /> — <br /> Y CalRecycle 181(Rev.10/10) Survey Form - Page 1 I1 1226642 <br /> Dept.of Resources Recycling and Recovery(Cal <br /> Part A-Survey _ _ BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- Inspection Type(Fill one) <br /> Site Suffix: l (� 5 b 0 1 • Routine 0 Re-inspection 0 Referral 0 Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier: '�)Ckv� 0 CHP 0 CalRecycle 0 Complaint 0 Educational Visit 0 Other <br /> Business or Facility Name Inspected By Inspector <br /> N�-O� <br /> Physical Ad8-r—ess J �. Q ✓r�b <br /> Inspection Date i l Z <br /> lA� `— � Time In Time Out <br /> Business Rep 1_ Title ^' ®AM O AM <br /> Vie 1eVkA- VA I�J�1�'i dr VA&121 J 0 PM O PM <br /> Operational Status Tire Type Business Role Storage Type <br /> Tire Count (Wh01 / ) (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> / 9 Active 0 Passenger ®Generator 0 Outdoor <br /> O 0 Closed Altered <br /> GPS Latitude 0 Hauler 0 Indoor <br /> o Q Inactive ® Truck <br /> Longitude - 0 Planned OTR End-Use ® Container <br /> Business Type(Fill all that apply) <br /> 0 New Tire Dealer 0 Auto Repair 0 Trucking Fleet ® 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 <br /> O 0 - 0 Notice Of Violation � Extension <br /> PRC§42951 Waste Tire Hauler Registration and Transport of Tires <br /> 0 0 PRC§42953-Contracts with Registered Waste Tire Haulers. Compliance Deadline <br /> PRC§42956-Registration/Decal in Vehicle <br /> 00 14 CCR§18459-Responsible Entities Complying with Manifesting Requirements Date M / M / Ffl <br /> 0 I0 14 CCR§18459.1 -Tire Program ID Number from CalRecycle a <br /> 0 0 14 CCR§18459.2.1 -Submittal of Comprehensive Trip Logs within 90 days (Required for NOV or EXT) N <br /> 0 0 14 CCR§18459.3-Retention of Comprehensive Trip Logs for 3 years o <br /> 0 0 14 CCR§18460.2-Manifest System Requirements for Registered Waste Tire Haulers 0 Referred/CalRecycle Enforcement <br /> LU <br /> 0 0 14 CCR§18461 -Manifest System Requirements for Waste Tire End-Use Facilities W <br /> 0 0 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators In Compliance- No Violations o <br /> 0 0 Other:§ _ <br /> Comments <br /> OF <br /> Inspection Form Included: 0 00 2 / <br /> Comments Included: J <br /> /F <br /> Busines ep's S n re Phone Number Ins a or' Si at re Phone Number <br /> INSTRUCTIONS ON BACK Correct:* E X AMP L E 1 ' 2 3 62081 <br /> ■ White Copy:CalRecycle Yellow Copy:Operator Pink Copy:LEA © ■ <br />