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Waste Tire Survey & Inspection Report' -.nspection Report Number ■ <br /> CalRec cle State of California <br /> Y CalRecycle 181(Rev.10/10) Survey Form - Page 1 I 1 - 1177717 <br /> Recycle) <br /> Dept.of Resources Recycling and Recovery(CalRecycle) Survey <br /> Part A-Survey BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- Inspection Type(Fill one) <br /> Site Suffix: J 3 6 01` Q 1 Routine Q Re-inspection Q Referral Q Observation <br /> Localc�� If Referral,choose referral type(Fill one) <br /> Identifier: J ` � U1� cowl,I� <br /> Q CHP Q CalRecycle Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name Inspected By Inspector <br /> Physical Address <br /> 4lfJJT� <br /> Inspection Date / .7 / <br /> ' Time In Time Out <br /> Business Rep Title O AM O AM <br /> —'e1iKLeA 1 Ui�CCA►�,-�-- I . 4 O ® PM 2- 0 j ® PM <br /> 6t* Ccv has t lis A-t,6 f,/13 <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 /> Q Active ® Passenger ® Generator Q Outdoor <br /> ® // <br /> O Closed Q Altered Q Hauler Q Indoor <br /> GPS Latitude <br /> O Q Inactive Q 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 If 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 STATU� <br /> V A HAULING AND MANIFEST REQUIREMENTS <br /> Q Q § - - Q Notice Of Violation Q Extension <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§1$459-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 EX7) N <br /> a <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 /> 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:§ _I z <br /> Comments r1tYi Y1Q� 3�✓t �Otc;15L1� r„ ..nr\ !:7"3C'k 4r h!© 14?.)Let 2w j <br /> V> <br /> ;s'jctAs <br /> Inspection Form Included: QComments Included: Q �Busines s Signature PhoneNum er Ini atu Phone Number <br /> 62081 <br /> INSTRUCTIONS ON BACK Correct:* Incorrect: � ® g E X A M E 1 2 3 <br /> ® White Copy:CalRecycle Yellow Copy:Operator Pink Cop :L ® ■ <br />