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Waste Tire S►,.. vey & Inspection Report Inspection Report Number ■ <br /> State of California <br /> CalRecycle — <br /> CalRecycle 181(Rev.10/10) I1 1242298 <br /> Dept.of Resources Recycling and Recovery(CalRecycle) Survey Form - Page 1 <br /> Part A-Survey ____ __ BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- Inspection Type(Fill one) <br /> O <br /> Site Suffix: 1 J J 0 Routine Q Re-inspection Q Referral Q Observation <br /> LocalIf Referral,choose referral type(Fill one) <br /> Identifier: 5w) cutAq1 U Q CHP Q CalRecycle Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name Inspected By Inspector <br /> Physical Address j GS�TT d <br /> C Inspection Date <br /> C) a 1 l <br /> L�k U A �SZ�S Time In Time Out 1 <br /> Business Rep Title 0 AM �{ 0 AM <br /> PM 4 � DPM <br /> 2pn �f�n �r SYIc, <br /> Operational Status Tire Type Business Role Storage Type <br /> Tire Count(Whole/PTE) N7 0 (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> 0 Active Q Passenger 0 Generator 0 Outdoor <br /> Q Closed Q Altered <br /> GPS Latitude Q Hauler Q Indoor <br /> O Q Inactive 0 Truck <br /> Longitude - Q Planned 0 OTR End-Use 0 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 Q Car Dealer Q Collection Q Crumb Rubber <br /> Q Service Station Q Hauler Q Agriculture Q Shredder 4N Other �� �y p� S 1�4 <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 / 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 EXn <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 01n Compliance-No Violations o <br /> Q Q Other:§ 46 <br /> - y ], <br /> Comments .1 04'Int, U7blS�C, �ti�, 1f1� 1])1\ &nj nn 468 ALute,_l���Tl-+"-' <br /> k 0A 0 V' D 1 NA 1,)333- -0 ON <br /> (� Q All olaR" (3 t wCw3 )A U)ntorn- <br /> Inspection Form Included: Q - G )-79 <br /> Comments Included: <br /> Business Rep's Signature U Phone Number Insp c or's Signature Phone Number <br /> INSTRUCTIONS ON BACK Correct:0 Incorrect: EXAM 1112 3 62081 <br /> White Copy:CalRecycle Yellow Copy:Operator Pink Copy: <br />