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Waste Tire SXey & Inspection ReportOnspection Report Number <br /> CalRec cle State of California <br /> Y CalRecycle 181(Rev.10/10) Survey Form - Page 1 11 1230203 <br /> Dept.of Resources Recycling and Recovery(CalRecycle) <br /> Part A-Survey BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- � O � a � - O 1 Inspection Type(Fill one) <br /> Site Suffix: "� -` 9 Routine 0 Re-inspection 0 Referral 0 Observation <br /> Local � If Referral,choose referral type(Fill one) <br /> Identifier: �ay% eTdv,h l_SJ V ��,/ 0 CHP 0 CalRecycle 0 Complaint 0 Educational Visit 0 Other <br /> Business or Facility Name / Inspected By Inspector <br /> Physical Address <br /> s32O Inspection Date <br /> Time In Time Out <br /> Business Rep Title //)� 0�, 10 AM i '* AM <br /> V V 0 PM 1 0 PM <br /> 6_01sl Operational Status Tire Type Business Role Storage Type <br /> Tire Count (Whole/PTE) i �j e1 (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> 1 ` L- *Active 9 Passenger e Generator 0 Outdoor <br /> O 0 Closed 0 Altered <br /> GPS Latitude 0 Hauler 0 Indoor <br /> O 0 Inactive % Truck <br /> Longitude - 0 Planned I$ OTR 0 End-Use 4W 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 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 /> 0 0 14 CCR§18459.3-Retention of Comprehensive Trip Logs for 3 years <br /> 0 <br /> 0 0 14 CCR§18460.2-Manifest System Requirements for Registered Waste Tire Haulers 0 Referred/CalRecycle Enforcement <br /> 2 <br /> 0 0 14 CCR§18461 -Manifest System Requirements for Waste Tire End-Use Facilities m <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 O'er _C?L2Q--Oh kkzs n t� <br /> ��V�c3►,a�i anS �c �ce�o.,5 0� Corice.c-�n <br /> Inspection Form Included: 0 <br /> Comments Included: <br /> Busin s Rep's Ignature Phone Number Inspector's Signature Phone Number <br /> INSTRUCTIONS ON BACK Correct:6 Incorrect: X � q IIEIXIAIMIP ILI E 1112 3 62081 <br /> ■ White Copy:CalRecycle Yellow Copy:Operator Pink Copy:LEA © ■ <br />