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ry & Inspection Re •r�nspection Report Number <br /> Waste Tire u ey p p � <br /> Cal Rec cle State of California <br /> Y CalRecycle 181(Rev.10/10) Survey Form - Page 1 I1 - 1196415 <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: ` LtLI Q 1 ®Routine 0 Re-inspection 0 Referral 0 Observation <br /> Local l If Referral,choose referral type(Fill one) <br /> Identifier: SC v" �1�C�,6,its �vi✓1� 0 CHP 0 CalRecycle 0 Complaint Q Educational Visit 0 Other <br /> Business or Facility Name Inspected By Inspector <br /> Physical Address p� ` [ C' 1 /a )' <br /> �Gv� L00 �lCJ <br /> Inspection Date / O <br /> Time In Time Out <br /> Business Rep Title / *AM I O AM <br /> 4 (� 0 PM ` Z Q ®PM <br /> v�l�.��� ��lc..l e`CJ �t✓1�•� <br /> Operational Status Tire Type Business Role Storage Type <br /> (Fill one only) (FII all that apply) (Fill all that apply) (FII all that apply) <br /> Tire Count (Whole/PTE) <br /> 1 ® Active O Passenger ® Generator I&Outdoor <br /> C 0 Closed 0 Altered <br /> GPS Latitude O Hauler 0 Indoor <br /> 0 0 Inactive 0 Truck <br /> Longitude - 0 Planned 0 OTR O End-Use O Container <br /> Business Type(Fill all that apply) <br /> ® New Tire Dealer 0 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 O Shredder O 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 PRC§42951 -Waste Tire Hauler Registration and Transport of Tires <br /> O Q PRC§42953-Contracts with Registered Waste Tire Haulers. Compliance Deadline <br /> 0 Q PRC§42956-Registration/Decal in Vehicle <br /> 0 0 14 CCR§18459-Responsible Entities Complying with Manifesting Requirements Date <br /> 0 O 14 CCR§18459.1 -Tire Program ID Number from CalRecycle a <br /> 0 O 14 CCR§18459.2.1 -Submittal of Comprehensive Trip Logs within 90 days (Required for NOV or EXE <br /> O O 14 CCR§18459.3-Retention of Comprehensive Trip Logs for 3 years o <br /> 0 O 14 CCR§18460.2-Manifest System Requirements for Registered Waste Tire Haulers 0 Referred/CalRecycle Enforcement <br /> 2 <br /> u, <br /> 0 O 14 CCR§18461 -Manifest System Requirements for Waste Tire End-Use Facilities <br /> Q O 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators ®In Compliance-No Violations o <br /> 0 O Other:§ z <br /> Comments <br /> Inspection Form Included: 0 <br /> Comments Included: <br /> "in' s Signature Phone Number In p Si ature Phone Number <br /> INSTRUCTIONS ON BACK Correct:0 incorrect: E X A M P L 1 2 3 62081 <br /> White Copy:CalRecycle Yellow Copy:Operator Pink Copy-L ® 0 <br />