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Waste Tire SuI►ve & Inspection Repo Report Number <br /> CalRecycle as y p p _ <br /> State of California <br /> Y CalRecycle 181(Rev.10/10) Survey Form - Page 1 1 1242155 <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: J �( �) 0 Routine 0 Re-inspection 0 Referral 0 Observation <br /> Local E If Referral,choose referral type(Fill one) <br /> Identifier: ,Ct,A Q0 CHP 0 CalRecycle 0 Complaint 0 Educational Visit 0 Other <br /> L/ <br /> Business or Facility Name Inspected By Inspector <br /> Cf-:c C,. 6 G V c- , isct t-"A C�- . � - <br /> Physical Address <br /> i.�j�"i f=t �-'r/►-rte.�_ �U I - <br /> t. Inspection Date / <e- <br /> v� �� �t�` T Time In Time Out• <br /> Business Rep�nn f Title ®AM ) ®AM <br /> ,-&1�,t i�,Y�ry •� k Glc-v''l'�_ / C : t O PM / � ✓ 0 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 /> ' 0 Active 0 Passenger 0 Generator 0 Ouuttdo/or <br /> O 0 Closed 0 Altered � " C <br /> GPS Latitude 0 Hauler 0 Indoor <br /> 0 Q Inactive ® 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 (a 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 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 /> 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 <br /> 0 0 14 CCR§18459.2.1 -Submittal of Comprehensive Trip Logs within 90 days (Required for NOV or EXT) N <br /> a <br /> 0 0 14 CCR§18459.3-Retention of Comprehensive Trip Logs for 3 years o <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 w <br /> 0 0 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators ®In Compliance-No Violations <br /> 0 0 Other:§ <br /> Comments <br /> Inspection Form Included: 0 <br /> Comments Included: 0 <br /> iness Rep's ignature Phone Number Ins ect is ign re Phone Number <br /> INSTRUCTIONS ON BACK Correct: Incorrect: NJ E X I AMP E 1 2 3 62081 <br /> White Copy:CalRecycle Yellow Copy:Operator Pink Copy: <br />