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Waste Tire'burvey & Inspection Repo, t Inspection Report Number ■ <br /> Cal Rec cle State of Cal'rfornia _ <br /> Y CalRecycle 181(Rev.10/10) Survey Form - Page 1 11 1226638 <br /> Dept.of Resources Recycling and Recovery(CalRecycle) <br /> Part A-Survey BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- ` Q 1 Q _ Q Inspection Type(Fill one) <br /> Site Suffix: t (9 ® Routine Q Re-inspection Q Referral Q Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier: u(� �� [,j)n C�Lt il� Q CHP Q CalRecycle Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name Inspected By Inspector <br /> Physical Address <br /> Inspection Date <br /> LA ����� <br /> Time In Time Out <br /> Business Rep Title AM ® AM <br /> p M l lJ V O PM S O PM <br /> -- Operational Status Tire Type Business Role Storage Type <br /> Tire Count (Whole/PTE) C' (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> D 16 Active (D Passenger ® Generator ® Outdoor <br /> o Q Closed Q Altered <br /> GPS Latitude Q Hauler Q Indoor <br /> O Q Inactive J) Truck Longitude — Q End-Use Q Container <br /> Q Planned Q OTR <br /> Business Type(Fill all that apply) <br /> Q New Tire Dealer Q Auto Repair Q Trucking Fleet Q Government Q Retreader 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 <br /> 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 <br /> Q Q 14 CCR§18459.2.1 -Submittal of Comprehensive Trip Logs within 90 days (Required for NOV or EXT) N <br /> 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 /> LU <br /> W <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 ®In Compliance-No Violations o <br /> Q Q Other:§ z <br /> Comments <br /> 1N o n U�ionz Oj Ul Jot'S 4 GU.nG1JR <br /> Inspection Form Included: Q <br /> Comments Included: ® ber <br /> Busin ss Rep's Si P one umInspe or's Signature Phone Number <br /> INSTRUCTIONS ON BACK Correct:40 Incorrect: 7V � C'X A M P L E 1 2 3 62081 <br /> . White Copy:CalRecycle Yellow Copy:Operator Pink Copy:LEA ® ■ <br />