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Waste Tire Survey & Inspection Report Inspection Report Number ■ <br /> Cal Rec cle State of California — <br /> Y CalRecycle 181(Rev.10/10) Survey Form - Page 1 1 1226386 <br /> Dept.of Resources Recycling and Recovery(CalRecycle) <br /> Part A- SurvyBLUE OR BLACK INK PEN <br /> Business Profile [Inspection Details <br /> TPID- Inspection Type(Fill one) <br /> Site Suffix: 3 Z', ® Routine 0 Re-inspection 0 Referral 0 Observation <br /> LocalL If Referral,choose referral type(Fill one) <br /> Identifier: S'�V-v ""Oe" /,MVS >l/►1�1 Z./ 0 CHP 0 CalRecycle 0 Complaint 0 Educational Visit 0 Other <br /> Business or Facility Name V Inspected By Inspector <br /> Physical�rek �3 <br /> 9c1 W (�-2t y1, - Lir✓ r lC� , <br /> Inspection Date / j --�7 <br /> rr � CA Q52' 7�, I. C <br /> l Time In Time Out <br /> Business Rep Title C� AM ®AM <br /> 0 PM 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 /> Active 0 Passenger ® Generator ® Outdoor <br /> O 0 Closed 0 Altered <br /> GPS Latitude 0 Hauler 0 Indoor <br /> O 0 Inactive 0 Truck <br /> Longitude - 0 Planned 0 OTR ® End-Use 0 Container <br /> Business Type(Fill all that apply) <br /> ® New Tire Dealer 4D Auto Repair 0 Trucking Fleet 0 Government 0 Retreader 0 Dismantler 0 Tire Derived Fuel <br /> 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 Notice Of Violation 0 Extension <br /> 0 0 <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 /> 0 0 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 0 <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 /> 2 <br /> Lu <br /> 0 0 14 CCR§18461 -Manifest System Requirements for Waste Tire End-Use Facilities <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 /> C <br /> Inspection Form Included: 0 Lo 67,14 <br /> Comments Included: � <br /> Bu iness Rep's Signa re P ne Number I s o ' i ature Phone Number <br /> n 62081 <br /> INSTRUCTIONS ON BACK [Correct.:* Incorrect: \H FETxjAjM P L E 1 2 3 <br /> ■ White Copy:CalRecycle Yellow Copy:Operator Pink Copy:LEA © ■ <br />