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Waste Tire Sup Bey & Inspection Report Inspection Report Number ■ <br /> CalRecle State of California <br /> cycle CalRecycle 181(Rev.10/10) Survey Form - Page 1 I1 - 1196465 <br /> Dept.of Resources Recycling and Recovery(CalRecycle) <br /> Survey <br /> A-Survey BLUE OR BLACK INK PEN_ <br /> less Profile Inspection Details <br /> �r)p_ � � � � -7 � � _ O � Inspection Type(Fill one) <br /> Site Suffix: ® Routine Q Re-inspection Q Referral Q Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier: 5�.h �O�V`^ ��� Q CHP Q CalRecycle Q Complaint Q Educational Visit Q Other <br /> Business or <br /> Facility Name \ / Inspected By Inspector <br /> Qrhhyslcal ss ( <br /> Inspection Date � 'v / � 6 � ` 3 <br /> ���c� r C1� 95206 <br /> Time In Time Out <br /> Business Rep Title G C AM 1 AM <br /> d 0 PM l 0 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 /> 0 ` Closed Q Altered`) r '01A A)1 <br /> GPS Latitude Q Hauler Q Indoor <br /> 0 Q Inactive Q Truck <br /> Longitude - Q Planned Q OTR Q End-Use Q Container <br /> Business Type(Fill all that apply) <br /> New 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 I* Other &:hMvK%,VA �� <br /> Part B - Inspection of Waste Tire Dealer, Generator, Hauler and End-Use Facility ENFORCEMENT STATUS <br /> V A HAULING AND MANIFEST REQUIREMENTS <br /> Q Notice Of Violation Q Extension <br /> Q Q <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 E)C7) <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 /> Q Q 14 CCR§18461 -Manifest System Requirements for Waste Tire End-Use Facilities W <br /> Q Q 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators In Compliance-No Violations o <br /> Q 1 Q Other:§ <br /> Comments <br /> —%->- <br /> %->- S <br /> Cv�c�c� <br /> .pection Form Included: Q <br /> Comments Included: r '� -�`�=I��`' /G� ?.`^q69 32-O <br /> Business Rep's Signature Phone Number Inspector's Signature Phone Number <br /> • �( <br /> INSTRUCTIONS ON BACK Correct: Incorrect: �/ E X A M P L E 1 2 3 62081 <br /> ■ White Copy:CalRecycle Yellow Copy:Operator Pink Copy:LEA © 0 <br />