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v <br /> Waste Tire Survey & Inspection Report inspection Report Number <br /> State of California <br /> Cal.Recycle CalRecycle 181(Rev.10/10) - 1230205 <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 5 9 o 0 Ro+Aine 0 Re-inspection 0 Referral 0 Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier: 0 CHP 0 CalRecycle 0 Complaint 0 Educational Visit 0 Other <br /> f <br /> Business or Facility Name V Inspected By Inspector <br /> Physical Address <br /> Inspection Date <br /> Time In 0 AM Time Out 0 AM <br /> Business Rep Title Z : * 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) <br /> 0 Active 0 Passenger 0 Generator 0 Outdoor <br /> o 0 Closed 0 Altere <br /> GPS Latitude Zjk 0_Hdlek, 0 1 do(Ar <br /> 0 0 Inactive 0 Truck <br /> Longitude 0 Planned 0 OTR 0 End-Use 0 Container <br /> Business Type(Fill all that apply) <br /> 0 New Tire Dealer 0 Auto Repair 40 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 /> / m <br /> 0 0 14 CCR§18459.1 -Tire Program ID Number from CalRecycle 0 <br /> 0 0 14 CCR§18459.2.1 -Submittal of Comprehensive Trip Logs within 90 days (Required for NOV or EXE <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 /> 0 0 Other:§ <br /> Comments ir) e C ;n <br /> Arve � NIN <br /> Inspection Form Included- <br /> . kj <br /> Comments Included: 0Phone Number <br /> Business Rep's Signature Phone Number Inspe or's Signature <br /> INSTRUCTIONS ON BACK Correct:* incorrect: ai� V — 62081 <br /> W [EIXIAIMI P FLT-EFTI[29 <br /> ■ White Copy:CalRecycle Yellow Copy:Operator Pink Copy:LEA <br />