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� r <br /> Waste Tire Survey & Inspection Report <br /> Inspection Report Number <br /> CalRecycle State of California <br /> CalRecycle 181(Rev.10/10) Survey Form - Page 1. I1 1230297 <br /> Dept.of Resources Recycling and Recovery(CalRecycle) <br /> Part A-Survey BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- r a n e Q I Inspection Type(Fill one) <br /> Site Suffix: l� l `1 0 Routine Q Re-inspection Q Referral Q Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier: Sit) J Q(.Lq w r) Cv un� Q CHP Q CalRecycle Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name <br /> Inspected By Inspector <br /> �A p S f 3 q _ t b G <br /> Physical Address e C C(Y 'T b <br /> Inspection Date l / 11 a / 1 S <br /> Time In Time Out <br /> Business Rep Title l Q So (1AM t � G 10 AM <br /> 0 PM S 0 PM <br /> Operational Status Tire Type Business Role Storage Type <br /> Tire Count (Whole/PTE) (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> l ' ° i Active Q Passenger I0 Generator Q Outdoor] <br /> O Q Closed Q Altered '"AA <br /> GPS Latitude Q Hauler Q Indoor <br /> O Q Inactive 40Truck <br /> Longitude - Q Planned Q OTR Q End-Use Q 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 /> 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 /> PRC§42956-Registration/Decal in Vehicle <br /> Q Q 14 CCR§18459-Responsible Entities Complying with Manifesting Requirements Date IT <br /> Q Q 14 CCR§18459.1 -Tire Program ID Number from CalRecycle <br /> Q Q 14 CCR§18459.2.1 -Submittal of Comprehensive Trip Logs within 90 days (Required for NOV or EXT) n <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 /> Q O 14 CCR§18461 -Manifest System Requirements for Waste Tire End-Use Facilities W <br /> Q Q 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators Sin Compliance- No Violations o <br /> Q Q Other:§ <br /> Comments �-e— f <br /> W(A<, <br /> I I � <br /> No 10 lr it S of anis Q c nAtt n <br /> Inspection Form Included: Q <br /> Comments Included: Sd J <br /> Business Rep's Signature Phone Number In ctor's Signature Phone Number <br /> INSTRUCTIONS ON BACK I Correct:* Incorrect: � EXAM L 1 2131 62081 <br /> White Copy:CalRecycle Yellow Copy:Operator Pink C.(9/ <br /> op L <br />