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LWiti\'-)JL�i_�:_il��kS11J]AYJ►1:�3►in4�:a?Lisi:�a •t:.�u�s:-�vtii�.Y s?z':,:•sva���tv....w..cw,uv....�..fa�.�.-o�.�-.-�y..>-��.+....._.-»�,-__,..__.�,.......-,._____... <br /> Waste Tire Survey & Inspection Report Inspection Report Number <br /> CalRec cle State of California <br /> Y CalRecycle 181(Rev.10/10) Survey Form - Page 1 11 1230185 <br /> Dept.of Resources Recycling and Recovery(CalRecycle) <br /> Part A-Survey BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> Inspection Type(Fill one) <br /> Site Suffix: / .10 Routine Q Re-inspection Q Referral Q Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier: 0.r �� v t �� Q CHP Q CalRecycle Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name }A� Inspected By Inspector <br /> Physical Address 3 1 M A�TT v <br /> ZO\ <br /> Inspection Date <br /> ( / os <br /> Time In 1 Time Out <br /> Business Rep Title i \ S AM <br /> C� QPM � S AM <br /> O PM <br /> ��`� v ae��UV Operational Status Tire Type Business Role Storage Type <br /> Tire Count (Whole/PTE) 1 1 (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> "� Active !Passenger 40 Generator 9 Outdoor <br /> O Q Closed Q Altered <br /> GPS Latitude Q Hauler Q indoor <br /> O Q Inactive Q Truck <br /> Longitude — Q Planned Q OTR O End-Use Q Container <br /> Business Type(Fill all that apply) <br /> New Tire Dealer 40 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 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 <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 /> 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 /> 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 /> LU <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 \ Y\� <br /> - -- Rov��r� <br /> ezz <br /> Inspection Form Included: Q <br /> Commentsincluded <br /> Busi ss ep's Signature hone um er Inspector's Signature Phone Number <br /> INSTRUCTIONS ON BAC [Correct.41 Incorrect: EXAMPLE 1 2 3 62081 <br /> ■ White Copy:CalRecycle Yellow Copy:Operator Pink Copy:LFA ® ■ <br />