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Waste Tire Sui vey & Inspection Report Inspection Report Number . <br /> Cal Rec cle State of California <br /> Y CalRecycle 181(Rev.10110) Survey Form - Page 1 1 - 1226595 <br /> Dept.of Resources Recycling and Recovery(CalRecycle) <br /> Part A-Survey BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- 1 Inspection Type(Fill one) <br /> Site Suffix: l g o l © t ® Routine Q Re-inspection Q Referral Q Observation <br /> Local /�� 1 If Referral,choose referral type(Fill one) <br /> Identifier: 5�� S Ci��( `� �--Cil�ln,( Z,� O CHP Q CalRecycle Q Complaint 0 Educational Visit Q Other <br /> Business or Facility Name (((1 Inspected By Inspector <br /> C icy-(,— A Cc,� <br /> Physical Add CA <br /> Inspection Date O / L Z 1 <br /> �' Time In Time Out l <br /> Business Rep Q \ Title ( ® AM ! O AM <br /> W�Z:.�/ t\C.tt1'�,VYL�%�,✓t. olvV��� � � � Cj 0 PM � � � G ® 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 ® Passenger ® Generator ® Outdoor <br /> Q Closed O Altered <br /> GPS Latitude Q Hauler 0 Indoor <br /> O Q Inactive O Truck <br /> Longitude - O Planned O OTR O End-Use Q Container <br /> Business Type(Fill all that apply) <br /> ® New Tire Dealer Q Auto Repair Q Trucking Fleet O Government Q Retreader Q Dismantler Q Tire Derived Fuel <br /> ® 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 Notice Of Violation Q Extension <br /> O O <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 /> O Q PRC§42956-Registration/Decal in Vehicle <br /> O Q 14 CCR§18459-Responsible Entities Complying with Manifesting Requirements Date m / m / m <br /> O Q 14 CCR§18459.1 -Tire Program ID Number from CalRecycle a <br /> Q Q 14 CCR§18459.2.1 -Submittal of Comprehensive Trip Logs within 90 days (Required for NOV or EXT) <br /> o O 14 CCR§18459.3-Retention of Comprehensive Trip Logs for 3 years <br /> O O 14 CCR§18460.2-Manifest System Requirements for Registered Waste Tire Haulers Q Referred/CalRecycle Enforcement <br /> W <br /> W <br /> O Q 14 CCR§18461 -Manifest System Requirements for Waste Tire End-Use Facilities <br /> O Q 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators A In Compliance-No Violations o <br /> Q Q Other:§ <br /> Comments <br /> G <br /> Inspection Form Included: Q q <br /> Comments Included: ® �����" �` ��� 4 64 <br /> Business %Signature Phone Number s I na re Phone Number <br /> !� 62081 <br /> INSTRUCTIONS ON BACK -Correct: Incorrect: X E X A E 1 2 3 <br /> ■ White Copy:CalRecycle Yellow Copy:Operator Pink Cop : © 0 <br />