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Waste Tire Su. ,rey & Inspection Report inspection Report Number ■ <br /> CalRec cle State of California — <br /> Y CalRecycle 181(Rev.10/10) Survey Form - Page i I1 1245165 <br /> Dept.of Resources Recycling and Recovery(CalRecycle) <br /> BLUE OR BLACK INK PEN <br /> Part A- Survey <br /> Business Profile Inspection Details <br /> TPID- � � � � � � - � Inspection Type(Fill one) <br /> Site Suffix: S 1 0 Routine Q Re-inspection Q Referral Q Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier: SO�Ir� �bQq��� � Q CHP Q CalRecycle0 Complaint Q Educational Visit Q Other <br /> Business or Facility Name 1 Inspected By Inspector <br /> Physical Address 1 0 AAe�q 1 J <br /> Inspection Date <br /> \10 Y\ Time In 1 Time Out 1 <br /> Business Rep Title I „\ O AM 0 AM <br /> U . PM � PM <br /> TC>V Vj �cv 0.��e.2 O W V\C-f- <br /> Operational Status Tire Type Business Role Storage Type <br /> Tire Count (Whole/PTE) <br /> (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> S7 0 Active Q Passenger 0 Generator 0 Outdoor <br /> O Q Closed Q Altered <br /> GPS Latitude Q Hauler Q Indoor <br /> O Q Inactive • Truck <br /> Longitude - O Planned 0 OTR O End-Use Q Container <br /> Business Type(Fill all that apply) <br /> Q New Tire Dealer O Auto Repair Trucking Fleet O Government Q Retreader Q Dismantler Q Tire Derived Fuel <br /> O Used Tire Dealer Q Auto Body Q Car Dealer O 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 PRC§42951 -Waste Tire Hauler Registration and Transport of Tires <br /> O O PRC§42953-Contracts with Registered Waste Tire Haulers. Compliance Deadline <br /> O O PRC§42956-Registration/Decal in Vehicle <br /> O O 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 EXT) N <br /> O 0 14 CCR§18459.3-Retention of Comprehensive Trip Logs for 3 years <br /> O Q 14 CCR§18460.2-Manifest System Requirements for Registered Waste Tire Haulers Q Referred/CalRecycle Enforcement <br /> Lu <br /> Lu <br /> O 0 14 CCR§18461 -Manifest System Requirements for Waste Tire End-Use Facilities <br /> O Q 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators •In Compliance-No Violations o <br /> O O Other:§ <br /> Comments e3Y'\ <br /> Inspection Form Included: O <br /> Comments Included: <br /> usiness Rep's Signature Phone Number Inspe or's Signature Phone Number <br /> INSTRUCTIONS ON BACK FCarrect-• Incrrect: X �oEXAMPLE I I 1 2 3 62081 <br /> ■ White Copy:CalRecycle Yellow Copy:Operator Pink Copy:LEA ® 0 <br />