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Waste Tire Survey & Inspection Report Inspection Report Number ■ <br /> State of California <br /> CalRecycle I 1 - 121010 5 <br /> CalRecycle 181(Rev. (Co) Survey Form - Page 1 <br /> Dept.of Resources Recycling and Recovery(CalRecycle) <br /> Survey <br /> A-Survey BLUE OR BLACK INK PEN <br /> less Profile Inspection Details <br /> e rID- -7 _ O 1 Inspection Type(Fill one) <br /> Site Suffix: � ® Routine 0 Re-inspection 0 Referral 0 Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier: �O �� y1 6j�y� / 0 CHP 0 CalRecycle 0 Complaint 0 Educational Visit 0 Other <br /> Business or Facility Name �j Inspected By Inspector <br /> Physical Address <br /> ""- 6� Inspection Date / Z 2. ` 3, <br /> S a o6enk 0Y\ CA `I <br /> Time In Time Out <br /> Business Rep Title 0 AM 0 AM <br /> 1 2 : 2 S 0 PM ' 1 ® 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 Outdoor <br /> O 0 Closed 0 Altered k IN- /�j 10- <br /> GPS Latitude fJ k 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 /> New Tire Dealer 0 Auto Repair 0 Trucking Fleet 0 Government 0 Retreader 0 Dismantler 0 Tire Derived Fuel <br /> Jsed 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 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 <br /> 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 EXE 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 o <br /> O 0 Other:§ `` \ `– \ <br /> Comments �v p^ ��S C1�Cl�'t� 011 fl(� <br /> Mn yz CSS Me�'_ — <br /> N dc�wrr�• �5�`��- C \WLP <br /> tC��S�ncaNhoy� \A c.15 G�Se cT . �2cow� � 'T�.:S l C o f <br /> _aection Form Included: 0 <br /> Comments Included: 0 <br /> Business Rep's Signature Phone Number Inspector's tignature Phone Number <br /> �, <br /> INSTRUCTIONS ON BACK Correct:* Incorrect: X � g E X A M P L E 1112 3 62081 <br /> ■ White Copy:CalRecycle Yellow Copy:Operator Pink Copy:LEA ® ■ <br />