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Waste Tire Siii,l vey & Inspection Repor• - Inspection Report Number ■ <br /> CalRec cle State of California <br /> Y CalRecycle 181(Rev.10/10) Survey Form - Page 1 I1 - 1226517 <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�r � � ' Inspection Type(Fill one) <br /> Site Suffix: C t 4 Routine Q Re-inspection Q Referral Q Observation <br /> Localc If Referral,choose referral type(Fill one) <br /> Identifier: vucv J G 0 CHP Q CalRecycle Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name Inspected By Inspector <br /> y cti�, D� � Y�� <br /> Physical Ad�ress <br /> Inspection Date <br /> v (?5--30q Time In Time Out l <br /> Business Rep I Title �PM M 0 AM <br /> � � � d ®•PM <br /> �%� c1 All" <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 ® Passenger ® Generator ® Outdoor <br /> O Q Closed Q Altered <br /> GPS Latitude 0 Hauler Q Indoor <br /> O Q Inactive Q Truck <br /> Longitude — Q Planned O OTR O End-Use O 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 ® 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 Notice Of Violation 0 Extension <br /> O O PRC§42951 -Waste Tire Hauler Registration and Transport of Tires <br /> O O PRC§42953-Contracts with Registered Waste Tire Haulers. Compliance Deadline <br /> O O PRC§42956-Registration/Decal in Vehicle <br /> O O 14 CCR§18459-Responsible Entities Complying with Manifesting Requirements Date <br /> O O 14 CCR§18459.1 -Tire Program ID Number from CalRecycle a <br /> O 0 14 CCR§18459.2.1 -Submittal of Comprehensive Trip Logs within 90 days (Required for NOV or EXTJ N <br /> O V 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 O Referred/CalRecycle Enforcement <br /> 2 <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 Generators In Compliance-No Violations o <br /> O O Other:§ <br /> - Z <br /> Comments <br /> Inspection Form Incl ed: Q 4 —'�2_0-iS"CO <br /> Comments Included: t �3 <br /> I* Business Rep' to Phone Number In a 9FAjdnature Phone Number <br /> INSTRUCTIONS ON BACK Correct: Incorrect: E X A P 1 2 3 62081 <br /> ■ White Copy:CalRecycle Yellow Copy:Operator Pink Co L ■ <br />