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Waste Tire Sulrvey & Inspection Repot L Inspection Report Number ■ <br /> Cal Rec cle State of California <br /> Y CalRecycle 181(Rev.10/10) Survey Form - Page 1 11 - 1226243 <br /> Dept.of Resources Recycling and Recovery(CalRecycle) <br /> PartA - Survey___- BLUE OR BLACK INK PEN <br /> Business Profile inspection Details <br /> TPID- Inspection Type(Fill one) <br /> Site Suffix: C I L` Jf' G Ci ( ® Routine 0 Re-inspection 0 Referral 0 Observation <br /> Local C \ 1 If Referral,choose referral type(Fill one) <br /> Identifier: CYAV1 0 CHP 0 CalRecycle 0 Complaint 0 Educational Visit 0 Other <br /> Business or Facility Name Inspected By Inspector <br /> Physical Address <br /> Inspection Date <br /> Time In Time Out <br /> Business Rep Title O AMO AM <br /> 40 PM PM <br /> V; 1(c� -- <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 Passe n er0 Generator 0 Outdoor <br /> Latitude D 0 Closed 0 Altered /A ®Hauler 0 IA <br /> GPS <br /> 0 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 ® 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 - 0 Notice Of Violation 0 Extension <br /> PRC§42951 -Waste Tire Hauler Registration and Transport of Tires <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 <br /> 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) n <br /> 0 0 14 CCR§18459.3-Retention of Comprehensive Trip Logs for 3 years <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 _. m <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� rj Z7 <br /> Inspection Form Included: M <br /> ct-e-16r <br /> Comments Included: ' s , 1 (o0z A <br /> L Bu s Rep's Signature Phone Number s ctor' Sig ture Phone Number <br /> INSTRUCTIONS ON BACK Correct:* Incorrect: E X 62081 A M 1 1 2 3 <br /> ■ White Copy:CalRecycle Yellow Copy:Operator Pink Copy © ■ <br />