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0 0 Waste Tire Sur vey & Inspection Report Inspection Report Number ■ <br />CalRecycle State of California — <br />CalRecycle 181(Rev.10/10) Survey Form -Page 1 I1 1210178 <br />Recycle) <br />Dept of Resources Recycling and Recovery (CalRecycle)Survey <br />)art A - Survey BLUE OR BLACK INK PEN <br />Business Profile Inspection Details <br />TPID - � - O � Inspection Type (Fill one) <br />Site Suffix: (� ® Routine Q Re -inspection Q Referral Q Observation <br />Local <br />Identifier: 54cl— <br />Business or Facility Name /7 <br />Physical Address <br />13 o Z ,) , <br />�- o <br />Business Rep <br />D z� h: S <br />Title <br />C.k gSzLjo <br />Tire Count (Whole/PTE) <br />G+PS Latitude <br />Longitude - <br />Business Type (Fill all that apply) <br />New Tire Dealer Q Auto Repair Q Trucking Fleet <br />Used Tire Dealer Q Auto Body Q Car Dealer <br />Q Service Station Q Hauler Q Agriculture <br />1 J0 <br />rd <br />If Referral, choose referral type (Fill one) <br />Q CHP Q CalRecycle Q Complaint Q Educational Visit Q Other <br />Inspected By Insppec�tor <br />sp\) <br />Inspection Date <br />Time In Time Out <br />O Q • AM � � � ®AM <br />0 P 0 P <br />Operational Status <br />Tire Type <br />Business Role <br />Storage Type <br />(Fill one only) <br />(Fill all that apply) <br />(Fill all that apply) <br />(Fill all that apply) <br />I* Active <br />9 Passenger <br />0 Generator <br />,Outdoor <br />Q Closed <br />Q Altered <br />Q Hauler <br />Q Indoor <br />Q Inactive <br />Q Truck <br />Q <br />Q <br />Q Planned <br />40 OTR <br />O End -Use <br />Q Container <br />U Government U Retreader Dismantler U Tire Derived Fuel <br />Q Collection Q Crumb Rubber <br />Q Shredder Q Other <br />Part B - Inspection of Waste Tire Dealer, Generator, Hauler and End -Use Facility <br />V <br />A <br />HAULING AND MANIFEST REQUIREMENTS <br />Q <br />Q <br />PRC § 42951 - Waste Tire Hauler Registration and Transport of Tires <br />Q <br />Q <br />PRC § 42953 - Contracts with Registered Waste Tire Haulers. <br />Q <br />Q <br />PRC § 42956 - Registration/Decal in Vehicle <br />Q <br />Q <br />14 CCR § 18459 - Responsible Entities Complying with Manifesting Requirements <br />Q <br />Q <br />14 CCR § 18459.1 - Tire Program ID Number from CalRecycle <br />Q <br />Q <br />14 CCR § 18459.2.1 - Submittal of Comprehensive Trip Logs within 90 days <br />Q <br />Q <br />14 CCR § 18459.3 - Retention of Comprehensive Trip Logs for 3 years <br />Q <br />Q <br />14 CCR § 18460.2 - Manifest System Requirements for Registered Waste Tire Haulers <br />Q <br />Q <br />14 CCR § 18461 - Manifest System Requirements for Waste Tire End -Use Facilities <br />Q <br />Q <br />14 CCR § 18462 - Manifest System Requirements for Tire Dealers or Waste Tire Generators <br />n <br />n <br />Other: § <br />ENFORCEMENT STATUS <br />Q Notice Of Violation Q Extension <br />Compliance Deadline <br />Datem / m / m <br />(Required for NOV or EXT) <br />Q Referred / CalRecycle Enforcement <br />join Compliance - No Violations <br />Mo \,% ok'Q_k 0•n S 0( %'c a.S c9 � Q0 v1CeC VA <br />Inspection Form Included: Q '-'�o7 <br />Comments Included: <br />P,siZnessep1s­SignaV*e Phonee Numb <br />2&q_gbs-may <br />Phone Number <br />INSTRUCTIONS ON BACK [Correct' 0 Incorrect: 1IEIXIAIMIPILIEI 1112 3 62081 <br />■ White Copy: CalRecycle Yellow Copy: Operator Pink Copy: LEA ® ■ <br />I <br />