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Waste Tire Survey & Inspection Repor ,, Inspection Report Number <br /> CalRec cle State of California _ <br /> Y CalRecycle 181(Rev.10/10) I1 1245094 <br /> Dept.of Resources Recycling and Recovery(CalRecycle) Survey Form - Page 1 <br /> Part A-Survey BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- � � � � _ � ( Inspection Type(Fill one) <br /> � <br /> Site Suffix: `� * Routine Q Re-inspection Q Referral Q Observation <br /> Local ^ If Referral,choose referral type(Fill one) <br /> Identifier: `�/p �, v 4)� Co(, o Q CHP Q CalRecycle Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name <br /> C® Inspected By Inspector <br /> Physical Address I 4,�1,,�1/AL I"l <br /> Inspection Date <br /> Gj�� als <br /> Time In Time Out <br /> Business Rep <br /> �FUI f Tile O AM � O AM <br /> 2- • OS9PM ` �*PM7� ILCLU�S tQ—ru'YLQ= / �, <br /> %erational Status Tire Type Business Role Storage Type <br /> Tire Count(Whole/PTE) (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> 0 Active Q Passenger 0 Generator a Outdoor <br /> Q Closed Q Altered <br /> GPS Latitude Q Hauler Q Indoor <br /> 0 Q Inactive 0—Truck <br /> Longitude - Q Planned Q OTR Q End-Use Q Container <br /> Business Type(Fill all that apply) <br /> Q New Tire Dealer Q Auto Repair 0 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 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 /> 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 / 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 EXE 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 /> uj <br /> Q Q 14 CCR§18461 -Manifest System Requirements for Waste Tire End-Use Facilities W <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 ,6 kc- <br /> � jo-yuo_ CTY ,:K� (� J� L?Z►2c <br /> 4 Cc�Y�(4 v✓1 <br /> Inspection Form�nc <br /> ncluded: Q <br /> Comments zyy <br /> luded: <br /> u ess ep's Signature Phone Number Inspect 's Sign Phone Number <br /> INSTRUCTIONS ON BACK Correct:is Incorrect: EXAMPLE 1112 3 62081 <br /> White Copy:CalRecycle Yellow Copy:Operator Pink Copy:LEA <br />