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Waste Tire vu, ve & Inspection ReplOLInspection Report Number ■ <br /> Cal Recycle y p <br /> y State of California I 1 - 117644. 8 <br /> CalRecycle 181(Rev.10/10) Survey Form - Page 1 1-�- <br /> Dept.of Resources Recycling and Recovery(CalRecycle) <br /> BLUE OR BLACK INK PEN <br /> Part A- Survey <br /> Business Profile Inspection Details <br /> TPIDInspection Type(Fill one) <br /> Site Suffix: I 6- ( 3 � �� -7 0 Routine 0 Re-inspection 0 Referral 0 Observation <br /> Local G, ` �-, If Referral,choose referral type(Fill one) <br /> Identifier: �X� ������ C C L�" �/ 0 CHP 0 CalRecycle 0 Complaint 0 Educational Visit 0 Other <br /> Business or Facility Name l Inspected By Inspector <br /> i <br /> Physical Address <br /> s2 tol �. 0�s lk <br /> Inspection Date 17;Z <br /> Time In Time Out <br /> Business Rep ritle 7 ® AM 1 ®AM <br /> -rr^/�i ��np 1tv J O 0 PM I l O PM <br /> AA e� Civ&, Y &_ Operational Status Tire Type Business Role Storage Type <br /> (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> Tire Count (Whole/PTE) ,�fi//' <br /> 0 Active ® Passenger ®Generator � Outdoor <br /> Closed 0 Altered <br /> GPS Latitude 0 Hauler 0 Indoor <br /> O 0 Inactive 0 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 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 0 Notice Of Violation 0 Extension <br /> 0 0 PRC§42951 -Waste Tire Hauler Registration and Transport of Tires <br /> 0 0 PRC§42953-Contracts with Registered Waste Tire Haulers. Compliance Deadline <br /> 0 0 PRC§42956-Registration/Decal in Vehicle <br /> 0 0 14 CCR§18459-Responsible Entities Complying with Manifesting Requirements Date m m m N <br /> 0 0 14 CCR§18459.1 -Tire Program ID Number from CalRecycle N <br /> 0 0 (Required for NOV or EXE — <br /> 14 CCR§18459.2.1 -Submittal of Comprehensive Trip Logs within 90 days r` <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 /> 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 0 In Compliance-No Violations o <br /> 0 1 0 Other:§ - ~ <br /> 4 <br /> Comments / <br /> Inspection Form Included: 0 <br /> Comments Included: <br /> 91 �o � <br /> Business Rep's Signature one Nu ber p t 's ignature Phone Number <br /> ,-,( 62081 <br /> INSTRUCTIONS ON BACK Correct:* Incorrect: � 6& NJ E X A M P L E 1 2 3 <br /> ■ White Copy:CalRecycle Yellow Copy:Operator Pink Copy:LEA © ■ <br />