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r t <br /> Waste Tire Su. ✓ey & Inspection Report inspection Report Number <br /> CalRecycle State of California I 1 - 1196513 <br /> CalRecycle181(Rev.10/10) <br /> (Cal Survey Form - Page 1 <br /> Dept.of Resources Recycling and Recovery(CalRecycle) <br /> ' A-Survey BLUE OR BLACK INK PEN <br /> less Profile Inspection Details <br /> 'I rID- Inspection� � S C _ O � Inspection Type(Fill one) <br /> �Site Suffix: _l J 0 Routine Q Re-inspection Q Referral Q Observation <br /> LocalIf Referral,choose referral type(Fill one) <br /> Identifier: Sc�.h JdC�gV� co <br /> Business <br /> Q CHP Q CalRecycle Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name V Inspected By Inspector <br /> PhysicalAddr ss� IC—C, <br /> 3 l - L \ 1 O <br /> Inspection Date / ` 7 / 1 3 <br /> ( <br /> `A 15530 Time In Time Out <br /> Business Rep Title0 AM 0 AM <br /> 1 d O PM I O 4b 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 /> ' Q Active Q Passenger Q Generator Q Outdoor <br /> 1(21 <br /> 0 Closed Q Altered <br /> GPS Latitude Q Hauler Q Indoor <br /> O Q Inactive Q Truck <br /> Longitude - Q Planned Q OTR Q End-Use Q Container <br /> c-•^iness Type(Fill all that apply) <br /> Jew Tire Dealer Q Auto Repair Q Trucking Fleet Q Government Q Retreader Q Dismantler Q Tire Derived Fuel <br /> Used Tire Dealer Q Auto Body Q Car Dealer Q Collection Q Crumb Rubber <br /> Q Service Station Q Hauler Q Agriculture Q Shredder Q Other <br /> Part B - Inspection of Waste Tire Dealer, Generator, Hauler and End-Use Facility ENFORCEMENT STATUS <br /> V I A I HAULING AND MANIFEST REQUIREMENTS <br /> Q Q PRQ Notice Of Violation Q Extension <br /> C§ -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 N <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) <br /> Q Q 14 CCR§18459.3-Retention of Comprehensive Trip Logs for 3 years <br /> 0 <br /> Q Q 14 CCR§18460.2-Manifest System Requirements for Registered Waste Tire Haulers Q Referred/CalRecycle Enforcement <br /> 2 <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 i In Compliance-No Violations o <br /> Q Q Other:§ <br /> Comments <br /> A IN U-s \/ma i N N_ <br /> 0 <br /> Ga MAMO _ <br /> ..,pection Form Included: Q <br /> Comments Included: 2�4��6�_32gH <br /> Business Rep's Signature Phone Number Insp�Signature Phone Number <br /> P 9 <br /> (� �( <br /> INSTRUCTIONS ON BACK I Correct:• Incorrect: �/ E X A M P L E 62081 1 2 3 ® ■ <br /> White Copy:CalRecycle Yellow Copy:Operator Pink Copy:LEA <br />