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Waste Tire SL... dey & Inspection Repor, Inspection Report Number ■ <br /> CalRecycle State of California I 1 - 1226629 <br /> CalRecycle 181(Rev.10/10) Survey Form - Page 1 <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: Ci 3 l O l 0 Routine Q Re-inspection Q Referral Q Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier. ���v` Q CHP Q CalRecycle Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name Inspected By Inspector <br /> CA\Physical Addres �' � 3 9 0 <br /> C}.-�-, �-y�� /�f� Inspection Date � � <br /> v`k V�k��/' \ � ct'���� Time In Time Out l <br /> �AM AM <br /> Business Rep Title <br /> t i r^, ; O 0 PM 1 ( d O PM <br /> �, 1� lq,vle ✓ l/ <br /> Operational Status Tire Type Business Role Storage Type <br /> r <br /> 3 (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> Tire Count (Whole/PTE) <br /> ® Active 0 Passenger ® Generator ® Outdoor <br /> O Q Closed Q Altered <br /> GPS Latitude Q Hauler Q Indoor <br /> O Q Inactive Q Truck <br /> Longitude - Q Planned Q OTR <br /> ® End-Use AS Container <br /> Business Type(Fill all that apply) <br /> New Tire Dealer Q Auto Repair Q Trucking Fleet Q Government Q Retreader Q Dismantler Q Tire Derived Fuel <br /> 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 /> 0 o PRC§42951 -Waste Tire Hauler Registration and Transport of Tires <br /> o ® PRC§42953-Contracts with Registered Waste Tire Haulers. Compliance Deadline <br /> 0 o PRC§42956-Registration/Decal in Vehicle <br /> Q o 14 CCR§18459-Responsible Entities Complying with Manifesting Requirements Date M / M / m <br /> 0 0 14 CCR§18459.1 -Tire Program ID Number from CalRecycle CO <br /> o Q 14 CCR§18459.2.1 -Submittal of Comprehensive Trip Logs within 90 days (Required for NOV or EXT) N <br /> a <br /> Q Q 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 Q Referred/CalRecycle Enforcement <br /> W <br /> W <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 o <br /> 0 o Other:§ <br /> Comments <br /> Inspection Form Included: �Sia <br /> p O ra� gComments Included: • Business Rep's Signature Phone Number pPhone Number <br /> 62081 <br /> INSTRUCTIONS ON BACK Correct:* Incorrect: EXAMPLE 1 2 3 <br /> ■ White Copy:CalRecycle Yellow Copy:Operator Pink Copy:LEA © ■ <br />