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Waste Tire Su. ,ey & Inspection Report inspection Report Number ■ <br /> cle State of California <br /> CalRecycle CalRecycle 181(Rev.10/10) Surrey Form _ Page 1 I1 - 1210109 <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 Q � � I Inspection Type(Fill one) <br /> Site Suffix: 1 b 0 Routine Q Re-inspection Q Referral Q Observation <br /> Local ` If Referral,choose referral type(Fill one) <br /> Identifier: � Av`V-\ �V� Q CHP Q CalRecycle Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name . ��` 777 Inspected By Inspector <br /> Physical Address <br /> Inspection Date <br /> Time In Time Out <br /> Business Rep Title 0 AM <br /> 1 C) '7 5O PM• AM 1 I ✓ 0 PM <br /> 1 L <br /> - -- Operational 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 /> *Active 0 Passenger 0 Generator 0 Outdoor <br /> Q Closed Q Altered <br /> GPS Latitude Q Hauler 0 Indoor <br /> O Q Inactive 0 Truck <br /> Longitude - Q Planned 0 OTR 0 End-Use Q Container <br /> Business Type(Fill all that apply) Ap CC G <br /> Q New Tire Dealer Q Auto Repair Q 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 <br /> PRC§42951 -Waste Tire Hauler Registration and Transport of Tires <br /> Q Q PRC§42953-Contracts with Registered Waste Tire Haulers. Compliance Deadline <br /> 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 EXT) <br /> Q Q 14 CCR§18459.3-Retention of Comprehensive Trip Logs for 3 years <br /> Q Q 14 CCR§18460.2-Manifest System Requirements for Registered Waste Tire Haulers Q Referred/CalRecycle Enforcement <br /> Q 1& 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 1 Q 1 Other:§ <br /> p 6 <br /> Comments <br /> See C <br /> of <br /> Inspection Form Included: Q ,,may yL p <br /> Comments Included: 0 `� <br /> Business Rep's Signature Phone Number Inspectis SI nature Phone Number <br /> INSTRUCTIONS ON BACK Correct:* Incorrect: ® � EXAMPLE 1112 3 62081 <br /> ® White Copy:CalRecycle Yellow Copy:Operator Pink Copy:LEA ® 0 <br />