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Waste Tire Survey & Inspection Rep Inspection Report Number <br /> � <br /> CalRecycle State of California <br /> CalRecycle 181(Rev.10/10) 11 - 12 2 6 3 8 7 <br /> Survey Form - Page 1 <br /> Dept.of Resources Recycling and Recovery(CalRecycle) BLUE OR BLACK INK PEN <br /> Part A- Survey _ --__—__-- -- <br /> Business Profile Inspection Details <br /> TPID- inspection Type(Fill one) <br /> Site Suffix: 5 J—7 l/ Fj Routine Q Re-inspection Q Referral Q Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier: tet(, ������ ^� Q CHP Q CalRecycle Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name Inspected By Inspector <br /> `i <br /> Physical Addre © rn K X-Ar <br /> Inspection Date / J <br /> l � ��`•� /� Time In Time Out <br /> Business Rep Title ''') r Q AM 0 AM <br /> Is PM L� A 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 /> Tire Count(Whole/PTE) f �p <br /> ® Active (� Passenger �1© Generator 4LOutdoor <br /> O Q Closed Q Altered <br /> GPS Latitude Q Hauler 'Indoor <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 /> ® New Tire Dealer IF Auto Repair Q Trucking Fleet Q Government Q Retreader Q Dismantler Q Tire Derived Fuel <br /> (it 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 STATUS <br /> V A HAULING AND MANIFEST REQUIREMENTS _ 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 <br /> Q Q 14 CCR§18459.1 -Tire Program ID Number from CalRecycle <br /> Q Q 14 (Required for NOV or EX7 N <br /> CCR§18459.2.1 -Submittal of Comprehensive Trip Logs within 90 days ^a <br /> U) <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 /> LU <br /> Q Q 14 CCR§18461 -Manifest System Requirements for Waste Tire End-Use Facilities <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 <br /> r <br /> Inspection Form Included: Q <br /> Comments Included: ®— — --Business Rep's Signatur Phone Number nspe Q 's _gn ure Phone Number <br /> —I_ - _ — — — <br /> _-- ��& <br /> 62081 <br /> INSTRUCTIONS ON BACK Correct:SIncorrect: (XE )CAM L 1 Z 3 <br /> ■ White Copy:CalRecycle Yellow Copy:Operator Pink Co :L © ■ <br />