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Oa Waste Tire Survey & Inspection Report Inspection Report Number ■ <br /> cle State of California <br /> CalRecycle 181(Rev.10/10) Survey Form - Page 1 I1 12 3 0 3 5 3 <br /> Dept.of Resources Recycling and Recovery(CalRecycle) <br /> Part A-Survey BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- ' 1 t o Inspection Type(Fill one) <br /> Site Suffix: ` 0 Routine Q Re-inspection Q Referral Q Observation <br /> LocalIf Referral,choose referral type(Fill one) <br /> Identifier: 1;wy-, w�,(� C�v �� Q CHP Q CalRecycle Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name \.J`-'" Inspected By Inspector <br /> Physical Address /V <br /> Inspection Date o $ / Z 2 <br /> 7� Time In Time Out <br /> Business Rep Title Au� ' t ; S PM C� ®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 /> I(p_ Q Active Q Passenger Q Genor Q,QtytEloor <br /> O a Closed Q Altere AX Nf//�►� <br /> GPS Latitude Q Hauler Q Indoor <br /> O Q Inactive Q Truc <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 Q 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 •Other `�re <br /> Part B- Inspection of Waste Tire Dealer,Generator, Hauler and End-Use Facility ENFORCEMENT STATUS <br /> V A HAULING AND MANIFEST REQUIREMENTS <br /> 6- <br /> Q Q Notice Of Violation Q Extension <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 Q 14 CCR§18459.1 -Tire Program ID Number from CalRecycle <br /> Q Q 14 CCR§18459.2.1 -Submittal of Comprehensive Trip Logs within 90 days (Required for NOV or EXT) N <br /> Q Q 14 CCR§18459.3-Retention of Comprehensive Trip Logs for 3 years <br /> Q Q 14 CCR§18460.2-Manifest System Requirements for Registered Waste Tire Haulers Q Referred/CalRecycle Enforcement <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 <br /> cmtic-e_V.2 Q15bW% 415 <br /> y� <br /> A V7 <br /> Inspection Form Included: Q -711 <br /> Comments Included: Q <br /> Business ep's S Phone N er Inspe or's Signature Phone Number <br /> 62081 <br /> INSTRUCTIONS ON BAC Correct:0 Incorrect: X E I X I A IMI P I L I E I1 2 3 <br /> ■ White Copy:CalRecycle Yellow Copy:Operator Pink Copy:LEA ® ■ <br />