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z <br /> Waste Tire Sup vey & Inspection Report inspection Report Number <br /> CalRecycle State of California I 1 - 1176752 <br /> CalRecycle 181(Rev.10/10) Survey Form - Page 1 <br /> Dept.of Resources Recycling and Recovery(CalRecycle) BLUE OR BLACK INK PEN <br /> Part A---,,Survey <br /> — <br /> Business Profile Inspection Details <br /> TPID- C Inspection Type(Fill one) <br /> Site Suffix: O Routine Q Re-inspection Q Referral Q Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier: �� Jc;C�C �n� - � Q CHP Q CalRecycle Q Complaint Q Educational Visit Q Other <br /> us <br /> Biness or Facility Name 1111 Inspected By Inspector <br /> Physical Address 2t��� l <br /> q Inspection Date ? © l I <br /> CA 1��� Time In L Time Out l <br /> Business Rep Title AM <br /> Q AM <br /> Go PM 1 ® 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 /> Active Q Passenger � Generator Q Outdoor <br /> D Q Closed I Q Altered <br /> GPS Latitude Q Hauler Indoor <br /> O Q Inactive Truck <br /> Longitude - Q Planned Q OTR <br /> Q End-Use Q Container <br /> i <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 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 / N <br /> Q Q 14 CCR§18459.1 -Tire Program ID Number from CalRecycle <br /> Q Q 14 (Required for NOV or EXT) N <br /> CCR§18459.2.1 -Submittal of Comprehensive Trip Logs within 90 days <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 /> Lu <br /> Q Q 14 CCR§18461 -Manifest System Requirements for Waste Tire End-Use Facilities <br /> Q Q 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators <br /> in Compliance-No Violations o <br /> Q Q Other:§ <br /> Comments <br /> Inspection Form Included: Q <br /> a�.�$'/yy� <br /> Comments Included: Q- -P -- ---- - <br /> usiness Re gnature Phone Number o ' ature Phone Number <br /> 62081 <br /> INSTRUCTIONS ON BACK Correct: Incorrect: A � E E 1 2 3 <br /> ■ White Copy:CalRecycle Yellow Copy:Operator Pink Copy: E © ■ <br />