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Waste Tire Survey & Inspection Report Inspection Report Number <br /> CalRecycle state of California <br /> Y CalRecycle 181(Rev.10/10) Survey Form - Page 1 I1 - 1177809 <br /> Dept.of Resources Recycling and Recovery(CalRacycle) <br /> Part A-Survey BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- � - Q � Inspection Type(Fill one) <br /> Site Suffix: 1 0 Routine Q Re-inspection Referral Q Observation <br /> Local 1 If Referral,choose referral type(Fill one) <br /> Identifier: San Qnl/',t r\ n O CHP ® CalRecycle Q Complaint Q Educational Visit 0 Other <br /> Business or Facility Name n Inspected By Inspector <br /> Physical Address <br /> - <br /> �� Inspection Date <br /> �`�JJ✓(�1^�I1 <br /> Time In Time Out <br /> Business Rep Title 0 AM 0 AM <br /> 0 PM 0 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 /> 7 ' <br /> Tire Count (Whole/PTE) /,J�_J <br /> Q Active 0 Passenger Q Generator O Outdoor <br /> O 0 Closed Q Alte etl lf� N� <br /> GPS Latitude Q HauleY Q Indoor A <br /> O Q Inactive Q Truck <br /> Longitude - Q Planned O OTR O End-Use Q Container <br /> Business Type(Fill all that apply) <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 O Crumb Rubber <br /> Q Service Station 0 Hauler Q Agriculture Q Shredder Q Other 1v/A <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 Notice Of Violation � Extension <br /> O O <br /> PRC§42951 -Waste Tire Hauler Registration and Transport of Tires <br /> Q 0 PRC§42953-Contracts with Registered Waste Tire Haulers. Compliance Deadline <br /> PRC§42956-Registration/Decal in Vehicle <br /> 0 Q 14 CCR§18459-Responsible Entities Complying with Manifesting Requirements Date m <br /> 0 Q 14 CCR§18459.1 -Tire Program ID Number from CalRecycle <br /> 0 0 14 CCR§18459.2.1 -Submittal of Comprehensive Trip Logs within 90 days (Required for NOV or F)C7) N <br /> a <br /> O 0 14 CCR§18459.3-Retention of Comprehensive Trip Logs for 3 years o <br /> O Q 14 CCR§18460.2-Manifest System Requirements for Registered Waste Tire Haulers Q Referred/CalRecycle Enforcement <br /> LU <br /> W <br /> O O 14 CCR§18461 -Manifest System Requirements for Waste Tire End-Use Facilities <br /> O O 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generatorsis In Compliance No Violations <br /> Q O Other:§ 11 LL z <br /> Comments t"WyT (/►S f1Gl"4o-A fi t1 l��10 K t -7 Og �Z N <br /> Inspection Form Included: O <br /> Comments Included: Q v _ <br /> Business Rep's Signature Phone Number Inspe is Signature Phone Number <br /> INSTRUCTIONS ON BACK [Correct: Incorrect: X �o g EXAMPLE 1 2 3 62081 <br /> White Copy:CalRecycle Yellow Copy:Operator Pink Copy:LEA <br />