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Waste Tire Su,vey & Inspection Report Inspection Report Number ■ <br /> CalRecycle State of California <br /> CalRecycle 181(Rev.10/10) I 1 1245274 <br /> Dept.of Resources Recycling and Recovery(CalRecycle) Survey Form - Page 1 <br /> Part A- Survqy—__ BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- S Inspection Type(Fill one) <br /> Site Suffix: ` y O 1 0 Routine Q Re-inspection Q Referral Q Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier: Zk r \ O CHP Q CalRecycle Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name Inspected By Inspector <br /> l v <br /> Physical Address o MST 1 <br /> r Inspection Date 6 Q r 1 7 / ) <br /> Time In 1, TimeOut <br /> Business Rep Title O Lt AM AM <br /> � O PM I l 6 O PM <br /> JCain) Operational Status Tire Type Business Role Storage Type <br /> Tire Count (Whole/PTE) <br /> 2 n (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> ''') L <br /> (i 0 Active 0 Passenger do Generator *Outdoor <br /> O Q Closed O Altered <br /> GPS Latitude Q Hauler Q Indoor <br /> O Q Inactive Q Truck <br /> Longitude — Q Planned Q OTR O End-Use Q Container <br /> Business Type(Fill all that apply) <br /> ® New Tire Dealer 0 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 0 Collection Q Crumb Rubber <br /> Q Service Station Q Hauler Q Agriculture Q Shredder O 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 /> Q Notice Of Violation Q Extension <br /> O O <br /> PRC§42951 -Waste Tire Hauler Registration and Transport of Tires <br /> O O PRC§42953-Contracts with Registered Waste Tire Haulers. Compliance Deadline <br /> PRC§42956-Registration/Decal in Vehicle <br /> O O 14 CCR§18459-Responsible Entities Complying with Manifesting Requirements Date m / m / m <br /> O O 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 EX7) <br /> O O 14 CCR§18459.3-Retention of Comprehensive Trip Logs for 3 years <br /> 0 <br /> O O 14 CCR§18460.2-Manifest System Requirements for Registered Waste Tire Haulers Q Referred/CalRecycle Enforcement <br /> Q O 14 CCR§18461 -Manifest System Requirements for Waste Tire End-Use Facilities W <br /> Q O 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators In Compliance-No Violations o <br /> O O Other:§ <br /> Comments �k <br /> Inspection Form Included: Q�Q1A. G L`"�O-� �I <br /> Comments Included: —--"\ l� K► (, (J <br /> ness Re ' nature Phone Number Inspec is Signature Phone Number <br /> �-,( <br /> INSTRUCTIONS ON B Correct:0 Incorrect: X � �J E X A M P L E 1112 3 62081 <br /> ■ White Copy:CalRecycle Yellow Copy:Operator Pink Copy:LEA © ■ <br />