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' ns ection Report Number <br /> Waste Tire Su, rey & Inspection Report - p � <br /> Cal Rec cle State of California <br /> Y CalRecycle 181(Rev.10/10) Survey Form - Page 1 I1 - 11 8 <br /> Dept.of Resources Recycling and Recovery(CalRecycle) <br /> Part A- Survey___ BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- Inspection Type(Fill one) <br /> Site Suffix: i ,` -7Cf 1 0 Routine Q Re-inspection Q Referral Q Observation <br /> Local (r If Referral,choose referral type(Fill one) <br /> Identifier: Z� ��`%�� '✓�`� L���' '1 Q CHP Q CalRecycleQ Complaint Q Educational Visit Q Other <br /> Business or Facility Name !! Inspected By Inspector <br /> Physica�Address , ,v <br /> Ll 1 �1 Inspection Date / <br /> Time In Time Out <br /> Business Rep Title __ O AM O AM <br /> _ I D ®PM J �� ® PM <br /> i�,Ltctir� �cti� ��✓� Pr y-e�MC4,v\.. <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 /> Q Active Q Passenger ®Generator Q Outdoor <br /> O Q Closed Q Altered <br /> GPS Latitude Q Hauler ® Indoor <br /> O Q Inactive ®Truck <br /> Longitude Q Planned OTRQ End-Use Q Container <br /> Business Type(Fill all that apply) <br /> Q New Tire Dealer Q Auto Repair ® 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 i;ry) cit 1/1 <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 Q PR - Q Notice Of Violation Q Extension <br /> C§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 / mN <br /> Q Q 14 CCR§18459.1 -Tire Program ID Number from CalRecycle R <br /> Q Q 14 CCR§18459.2.1 -Submittal of Comprehensive Trip Logs within 90 days (Required for NOV or EXE N <br /> Q Q 14 CCR§18459.3-Retention of Comprehensive Trip Logs for 3 years <br /> Q Q 14 CCR§18460.2-Manifest System Requirements for Registered Waste Tire Haulers Q Referred/CalRecycle Enforcement <br /> Lu <br /> Lu <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 <br /> Inspection Form Included: Q <br /> Comments Included: <br /> Business Rep's Signature Phone Number Insp r s Sig at a Phone Number <br /> ` 62081 <br /> INSTRUCTIONS ON BACK Correct: Incorrect: E X A' M P . E 1 2 3 <br /> ■ White Copy:CalRecycle Yellow Copy:Operator Pink Copy:LEA © ■ <br />