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Waste Tire Survey & Inspection Report Inspection Report Number <br /> cle State of California <br /> CalRecycle — <br /> Y CalRecycle 181(Rev.10/10) Survey Form - Page 1 I1 1177740 <br /> Dept of Resources Recycling and Recovery(CalRecycle) <br /> Part A-Survey BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- � � � - • � Inspection Type(Fill one) <br /> Site Suffix: l� O 46 Routine 0 Re-inspection 0 Referral 0 Observation <br /> Local SQ.h. �� f_ _ -L If Referral,choose referral type(Fill one) <br /> --Identifier_ '-WY�.Tl.(J 0-CHP Q-CalRecycle-e-Complaint o-Educational-Visit Q-Other— <br /> Business or Facility Name Inspected By Inspector <br /> Physical Acyress ` APA a,6 ULA <br /> �} <br /> /} Inspection Date <br /> L vc-) t ( `l� C� V <br /> Time In Time Out <br /> Business Rep Title O AM O AM <br /> A,PM J_ ® 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) Ct <br /> ® Active ® Passenger ®Generator 0 Outdoor <br /> 0 0 Closed 0 Altered <br /> GPS Latitude 0 Hauler (00 Indoor <br /> 0 0 Inactive 0 Truck <br /> Longitude - 0 Planned 0 OTR 0 End-Use 0 Container <br /> Business Type(Fill all that apply) <br /> ® New Tire Dealer 0 Auto Repair 0 Trucking Fleet 0 Government 0 Retreader 0 Dismantler 0 Tire Derived Fuel <br /> ® Used Tire Dealer 0 Auto Body 0 Car Dealer 0 Collection 0 Crumb Rubber <br /> 0 Service Station 0 Hauler 0 Agriculture 0 Shredder 0 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 /> 0 0 PRC§42951 -Waste Tire Hauler Registration and Transport of Tires 0 Notice Of Violation Extension <br /> 0 0 PRC§42953-Contracts with Registered Waste Tire Haulers. Compliance Deadline <br /> 0 0 PRC§42956-Registration/Decal in Vehicle <br /> 0 0 14 CCR§18459-Responsible Entities Complying with Manifesting Requirements Datem / m <br /> 0 0 14 CCR§18459.1 -Tire Program ID Number from CalRecycle a <br /> 0 0 14 CCR§18459.2.1 -Submittal of Comprehensive Trip Logs within 90 days (Required for NOV or EXT) N <br /> a <br /> 0 0 14 CCR§18459.3-Retention of Comprehensive Trip Logs for 3 years <br /> 0 0 14 CCR§18460.2-Manifest System Requirements for Registered Waste Tire Haulers 0 Referred/CalRecycle Enforcement s <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 <br /> in Compliance-No Violations o <br /> 0 1 0 1 Other:§ <br /> z <br /> Comments <br /> See YYICt'li <br /> P <br /> Inspection Form Included: 0 ^�� <br /> Comments Included: 0 <br /> B siness Rep's Signature Phone Number In a or' n ur Phone Number <br /> INSTRUCTIONS ON BACK Correct* Incorrect: E X AP 12131 62081 <br /> White Copy:CalRecycle Yellow Copy:Operator Pink Copy:L © 0 <br />