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02 Waste Tire Su, ijey & Inspection Report nspection Report Number ■ <br /> cle State of California <br /> CalRecycle 181(Rev.10/10) Survey Form - Page 1 I1 1230212 <br /> Dept.of Resources Recycling and Recovery(CalRecycle) <br /> Part A- Surve BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- ' � O ' Inspection Type(Fill one) <br /> Site Suffix: Is Routine 0 Re-inspection 0 Referral 0 Observation <br /> Local ` If Referral,choose referral type(Fill one) <br /> Identifier: �Go�v`^ 0 CHP 0 CalRecycle 0 Complaint 0 Educational Visit 0 Other <br /> Business or Facility Name ^n Inspected By Inspector <br /> Ca�,-,koc f\"� t \G C CA S T-h.0_ (� , 0 1 M <br /> Physical Address _V <br /> Inspection Date <br /> Time In Time Out <br /> Business Rep Title *AM \ *AM <br /> O Q PM I Q 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 /> 0 Active 0 Passenger 0 Generator 0 Outdoor <br /> 0 Closed 0 Altered <br /> GI P.�+7 Latitude 0 Hauler 0 Indoor <br /> O 0 Inactive 0 Truck <br /> Longitude - 0 Planned 0 OTR 0 End-Use 0 Container <br /> Business Type(Fill all that apply) <br /> 0 New Tire Dealer 0 Auto Repair 0 Trucking Fleet 0 Government 0 Retreader 0 Dismantler 0 Tire Derived Fuel <br /> 0 Used Tire Dealer 0 Auto Body 0 Car Dealer 0 Collection 0 Crumb Rubber <br /> 0 Service Station 0 Hauler 0 Agriculture 0 Shredder 0 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 /> 0 0 PRC§42951 -Waste Tire Hauler Registration and Transport of Tires 0 Notice Of Violation 0 Extension <br /> 0 0 PRC§42953-Contracts with Registered Waste Tire Haulers. Compliance Deadline <br /> PRC§42956-Registration/Decal in Vehicle <br /> 0 0 14 CCR§18459-Responsible Entities Complying with Manifesting Requirements Date M / m / m <br /> 0 0 14 CCR§18459.1 -Tire Program ID Number from CalRecycle <br /> 0 0 14 CCR§18459.2.1 -Submittal of Comprehensive Trip Logs within 90 days (Required for NOV or EXT) <br /> 0 0 14 CCR§18459.3-Retention of Comprehensive Trip Logs for 3 years o <br /> 0 0 14 CCR§18460.2-Manifest System Requirements for Registered Waste Tire Haulers 0 Referred/CalRecycle Enforcement <br /> 0 0 14 CCR§18461 -Manifest System Requirements for Waste Tire End-Use Facilities - w <br /> 0 0 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators In Compliance No Violations o <br /> 0 0 Other: <br /> Comments <br /> L -ire ��. <br /> Inspection Form Included: 0 l� E <br /> Comments Included: e ` G J <br /> esinedARep';Sign ure Phone Number Insp tor ��''s SignCS''ature Phone Number <br /> INSTRUCTIONS ON BACK Correct:0 Incorrect: X0 7q] E X A M L 1 2 3 62081 <br /> ■ White Copy:CalRecycle Yellow Copy:Operator Pink(top <br /> : ® 0 <br />