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Waste Tire Suk r/ey & Inspection Report inspection Report Number ■ <br /> State of California <br /> CalRecycle I 1 - 1196318 <br /> CalRecycle 181(Rev.10/10) <br /> (Cal Survey Form - Page 1 <br /> Dept.of Resources Recycling and Recovery(CalRecycle) <br /> Part A- Survey BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- _ Inspection Type(Fill one) <br /> Site Suffix: <br /> 1 � _7 0 Routine Q Re-inspection Q Referral Q Observation <br /> Localc , If Referral,choose referral type(Fill one) <br /> Identifier: )C,tV\ cX.1 _ � / Q CHP Q CalRecycle Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name Inspected By Inspector <br /> Is l� - 1 Ca t 1� JAY`?13 Z/L <br /> Physical Address <br /> Inspection Date <br /> Time In Time Out <br /> Business Rep Title <br /> 1 Title O AM O AM� <br /> lJ` l VC/1`�. 21't} -7"'✓G1 �„� 0 0 PM PPM <br /> Operational Status Tire Type Business Role Storage Type <br /> Tire Count(Whole/PTE) ,1 (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> �- ® Active Q Passenger ® Generator Q Outdoor <br /> O Q Closed Q Altered <br /> GPS Latitude Q Hauler ® Indoor <br /> O Q Inactive 49 Truck <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 /> Q Q PRC§42956-Registration/Decal in Vehicle <br /> Q Q 14 CCR§18459-Responsible Entities Complying with Manifesting Requirements Date M / m / m <br /> Q Q 14 CCR§18459.1 -Tire Program ID Number from CalRecycle -q <br /> Q Q 14 CCR§18459.2.1 -Submittal of Comprehensive Trip Logs within 90 days (Required for NOV or EXT) <br /> Q Q 14 CCR§18459.3-Retention of Comprehensive Trip Logs for 3 years <br /> Q Q 14 CCR§18460.2-Manifest System Requirements for Registered Waste Tire Haulers Q Referred/CalRecycle Enforcement <br /> Q Q 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 *In Compliance-No Violations o <br /> Q Q Other:§ <br /> Comments <br /> Inspection Form Includ <br /> Comments Included: C <br /> Business Rep's Signature Phone Number In p tor' gna re Phone Number <br /> INSTRUCTIONS ON BACK Correct: Incorrect: � 62081 <br /> E A 1112131 <br /> ■ White Copy:CalRecycle Yellow Copy:Ope t r Pink Cop . © ■ <br />