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0 Waste Tire Survey & Inspection Report Inspection Report Number ■ <br /> CalRecycle State of California <br /> Y CalRecycle 181(Rev.10/10) Survey Form - Page 1 11 - 1226655 <br /> Dept.of Resources Recycling and Recovery(CalRecycle) <br /> Part A-Survey __ BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- y - 0 Inspection Type(Fill one) <br /> Site Suffix: I Is Routine Q Re-inspection Q Referral Q Observation <br /> Local / If Referral,choose referral type(Fill one) <br /> Identifier: 0 fig,�u t n C Uu Q CHP Q CalRecycle Q Complaint Q Educational Visit Q Other <br /> Business or FacilityName <br /> II Inspected By Inspector <br /> ` <br /> Physical Address bl \JQ 3 <br /> Inspection Date a / 0 I / <br /> Time In Time Out <br /> Business Rep 1 Al1I I Title 5rl 0 PM I �J 0 AM <br /> 0 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 Q Passenger * Generator Q Outdoor <br /> O Q Closed Q Altered <br /> GPS Latitude Q Hauler ® Indoor <br /> O Q Inactive 10 Truck <br /> Longitude - Q Planned Q OTR Q 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 Q 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 /> Q Notice Of Violation Q Extension <br /> Q Q <br /> PRC§42951 -Waste Tire Hauler Registration and Transport of Tires <br /> Q Q PRC§42953-Contracts with Registered Waste Tire Haulers. Compliance Deadline <br /> PRC§42956-Registration/Decal in Vehicle <br /> Q Q 14 CCR§18459-Responsible Entities Complying with Manifesting Requirements Date M / m / m <br /> Q O 14 CCR;§18459.1 -Tire Program ID Number from CalRecycle a <br /> Q O 14 CCR§18459.2.1 -Submittal of Comprehensive Trip Logs within 90 days (Required for NOV or EXE N <br /> a <br /> Q ® 14 CCR§18459.3-Retention of Comprehensive Trip Logs for 3 years o <br /> Q Q 14 CCR§18460.2-Manifest System Requirements for Registered Waste Tire Haulers Q Referred/CalRecycle Enforcement <br /> Uj <br /> W <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 O ilk L��hS�� 111c'1_ nsP 10QCJ' 0f_ l <br /> Inspection Form Included: Q y + ` <br /> Comments Included: _9)3- <br /> 7 01 <br /> Business Rep' l i <br /> s Signature Phone Number Inspect 's Signatjjre Phone Number <br /> 62081 <br /> INSTRUCTIONS ON BACK Correct:0 Incorrect: X EN A E 1 2 3 <br /> ■ White Copy:CalRecycle Yellow Copy:Operator Pink C py A © ■ <br />