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Waste Tire Survey & Inspection Report Inspection Report Number ■ <br /> Cal Recycle State of California I 1 - 1226611 <br /> CalRecycle181(Rev.10/10) Survey Form - Page 1 <br /> Dept.of Resources Recycling and Recovery(CalRecycle) <br /> BLUE OR BLACK INK PEN <br /> Part A-Survey <br /> Business Profile Inspection Details <br /> TPID- Inspection Type(Fill one) <br /> Site Suffix: 6 r 1 0 Routine Q Re-inspection Q Referral Q Observation <br /> Local (� , If Referral,choose referral type(Fill one) <br /> Identifier: 1�1 c. 't)L/l Q CHP Q CalRecycle Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name Inspected By Inspector <br /> Physical Address <br /> / _ 1 Inspection Date <br /> Time In Time Out <br /> Business Rep Title ) AM 0 AM <br /> 7 ( 5� 0 PM PM <br /> Operational Status Tire Type Business Role Storage Type <br /> (Fill one only) all that apply) (Fill all that apply) (Fill all that apply) <br /> Tire Count(Whole/PTE) 0 <br /> fil Active Passenger ® Generator # Outdoor <br /> Q Closed Q Altered <br /> GPS Latitude Q Hauler Q Indoor <br /> 0 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 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 ® Other V1 o fC t qpq :(,/ <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 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 EXT) N <br /> a <br /> N <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 /> W <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 f _ <br /> Inspection Form Included: Q < < "S60MQ� <br /> Comments Included: ® a _19M Am —417.6Bus ess Rep's Signature Phone Number In p tors g lure Phone Number <br /> 62081 <br /> INSTRUCTIONS ON BACK Correct:* Incorrect: E X A M 1 2 3 <br /> ■ White Copy:CalRecycle Yellow Copy:Operator Pink Copy: © ■ <br />