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Waste Tire Sup vey & Inspection Report - inspection Report Number <br /> CalRec cle State of California — <br /> Y CalRecycle 181(Rev.10/10) Survey Form - Page 1 11 1229918 <br /> Dept.of Resources Recycling and Recovery(CalRecycle) <br /> Sart A-Survey_ BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- Q O Ins a t. Type(Fill one) <br /> Site Suffix: S 5 Z u 2 uttilne Re-inspection 0 Referral 0 Observation <br /> Local _ If Referral,choose referral type(Fill one) <br /> Identifier: ��- �1,v 4 V 0 CHP 0 CalRecycle 0 Complaint 0 Educational Visit 0 Other <br /> Business or Facility Name Inspected By Inspector <br /> Physical Address <br /> Inspection Dates <br /> -o�k�r.ct, <br /> Time In Time Out <br /> Business Rep Title 10 AM 1 ®AM <br /> \�� QPM I 1 � � QPM <br /> �1wC92e �i�Y1�� �t�sY'�� <br /> - �----- v 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 .Generator 9 Outdoor <br /> ( O 0 Closed 0 Altered <br /> GPS Latitude 0 Hauler 0 Indoor <br /> 0 0 Inactive @ Truck <br /> Longitude – 0 Planned 0 OTR 0 End-Use 40 Container <br /> Business Type(Fill all that apply) <br /> 0 New Tire Dealer 0 Auto Repair 0 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 / 0 <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 EXE 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 /> E <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 <br /> 0 0 Other:§ <br /> Comments <br /> Cp Ir .V �i C QA <br /> �(IPt:au5 v; al ave V.-.S (ne�r, r cfe-c" <br /> )9A oC��t�.�iUte _ C' i� (`�PG,� C_ov\ r n <br /> Inspection Form Included: D <br /> Comments Included: 0— <br /> Business <br /> Business Rep's Signature Phone Number AInspects Signature Phone Number <br /> INSTRUCTIONS ON BACK Correct: Incorrect: E X A M P L E 1 2 3 1 62081 <br /> ■ White Copy:CalRecycle Yellow Copy:Operator Pink Copy:LEA �� <br />