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Waste Tire purvey & Inspection Report Inspection Report Number <br /> cle State of California <br /> CalRecycle — <br /> Y CalRecycle 181(Rev.10/10) Survey Form - Page 1 I l 1245198 <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 Type(Fill one) <br /> Site Suffix: ® Routine Q Re-inspection Q Referral Q Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier: V- �� - �a` Q CHP Q CalRecycle Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name Inspected By Inspector <br /> Del `7 <br /> Physical Addre s <br /> Inspection Date j U Z <br /> / <br /> � <br /> Time In Time Out <br /> Business Rep Title O AM n O AM <br /> I 0 PM � ll 0 PM <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 Q Passenger 0 Generator Q Out oor <br /> Q Closed Q Altered <br /> GPS Latitude Q Hauler Q Ind or <br /> O Q Inactive Q Truck <br /> Longitude — Q Planned ® OTR Q 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 0 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 <br /> Other Ayck� , � WC 3 <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 /> Q Q PRC§42956-Registration/Decal in Vehicle <br /> Q Q 14 CCR§18459-Responsible Entities Complying with Manifesting Requirements Date 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 <br /> Q Q 14 CCR§18460.2-Manifest System Requirements for Registered Waste Tire Haulers Q Referred/CalRecycle Enforcement <br /> 2 <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 ,Compliance-No Violations o <br /> Q Q Other:§ <br /> CommentsC.t'ejet � -k, a611?,P 1� �L <br /> OLS�- 1k.-Q— l(CLL) ca 50 P L�4C�" <br /> V-,-6 V tb Lce±C=vL,,.-�j C-r koro <br /> Inspection Form Included: Q <br /> Lv Y <br /> Comments Included: <br /> Business Cep's Sig ture Phone Number('� Inspector's Signature Phone Number <br /> INSTRUCTIONS ON BACK Correct:0 Incorrect: E X A M P L E 1112 3 62081 <br /> 0 White Copy:CalRecycle Yellow Copy:Operator Pink Copy:LEA <br />