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r i <br /> Waste Tire Survey & Inspection Report fnspection Report Number . <br /> CalRecycle 1 <br /> State of California l 1 �--6. f b I <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 /> Business Profile Inspection Details <br /> Inspection Type(Fill one) <br /> TPID- <br /> Site Suffix: I L-I $ ® l✓ I Q Routine ® Re-inspection Q Referral Q Observation <br /> Local ,,,,� If Referral,choose referral type(Fill one) <br /> Identifier. so"VI �0ck% Q CHP Q CalRecycle Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name Inspected By Inspector <br /> 4 <br /> Physical Address AT ` ` - l -vr'e ,m'ej ( <br /> V Inspection Date <br /> cz, ., -1 cf_�`��O Time In 1 Time Out <br /> Business Rep Title O AM 0 AM <br /> L ® PM '� 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) 1 110 ® Active ® Passenger ® Generator Q Outdoor <br /> O Q Closed Q•Altered <br /> GPS Latitude Q Hauler Q Indoor <br /> o Q Inactive ® Truck <br /> Longitude - Q Planned Q OTR Q End-Use ® Container <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 CCR§ (Required for NOV or EXT) N <br /> 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 /> Enforcement <br /> cle <br /> Q Q 14 CCR§18460.2-Manifest System Requirements for Registered Waste Tire Haulers Q Referred/CalRecycle Lu <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 *in Compliance-No Violations o <br /> Q Q Other:§ <br /> Comments <br /> h <br /> Inspection Form Included: Q / , LLB( 0 -� <br /> Comments Included: � Bu s igna Phone Nu b r} 7 I s a re Phone Number <br /> - 1 2 3 62081 <br /> INSTRUCTIONS ON BAC Correct: Incorrect: W E A' _ ■ <br /> White Copy:CalRecycle Yellow Copy:Operator Pink Copy <br /> ■ <br />