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r <br /> Waste Tire Sur vey & Inspection Report Inspection Report Number <br /> Cal Rec cle State of California <br /> Y CalRecycle 181(Rev.10/10) Survey Form - Page 1 10/10) 11 1177694 <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: Q Q ,` © 1 0 Routine 0 Re-inspection 0 Referral 0 Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier: �� ��C� �� ���� � 0 CHP 0 CalRecycle 0 Complaint 0 Educational Visit 0 Other <br /> Business or Facility Name Inspected By Inspector <br /> Physical Address <br /> Inspection Date C / t �1 i <br /> Time In Time Out <br /> Business Rep Title AMJJ ® AM 1 1 � � O PM l � ' � QPM <br /> Operational Status Tire Type Business Role Storage Type <br /> Tire Count (Whole/PTE) Li (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> l If Active 0 Passenger 0 Generator ® Outdoor <br /> O 0 Closed 0 Altered <br /> ��� Latitude 0 Hauler ® Indoor <br /> O 0 Inactive Q Truck <br /> Longitude — 0 Planned OTR 0 End-Use 0 Container <br /> Business Type(Fill all that apply) <br /> 0 New Tire Dealer 0 Auto Repair 0 Trucking Fleet 0 Government 0 Retreader 0 Dismantler 0 Tire Derived Fuel <br /> 0 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 / m a <br /> 0 0 14 CCR§18459.1 -Tire Program ID Number from CalRecycle N <br /> 0 0 14 CCR§18459.2.1 -Submittal of Comprehensive Trip Logs within 90 days (Required for NOV or EXn <br /> 0 0 14 CCR§18459.3-Retention of Comprehensive Trip Logs for 3 years o <br /> 0 0 14 CCR§18460.2-Manifest System Requirements for Registered Waste Tire Haulers 0 Referred/CalRecycle Enforcement <br /> 2 <br /> W <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 ®in Compliance-No Violations o <br /> 0 1 0 Other:§ . <br /> Comments <br /> �f��i (.f712112�f't L N <br /> Inspection Form Included: 0 ^� <br /> v68- <br /> Comments Included: <br /> usi s4Rep's Phone Number In ct Signature Phone Number <br /> INSTRUCTIONS ACK Correct:* Incorrect: ® �j E X A L E 3 62081 <br /> ® White Copy:CalRecycle Yellow Copy:Operator Pink Co :L ® ■ <br />