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Waste Tire Survey & Inspection Report Inspection Report lumber <br /> CalRecycle State of California I 1 - 1230357 <br /> CalRecycle 181(Rev.10/10) Survey Form - gage 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 /> TPID- Inspection Type(Fill one) <br /> Site Suffix: ® Routine Q Re-inspection Q Referral Q Observation <br /> Local c - If Referral,choose referral type(Fill one) <br /> Identifier. �CA��/�' ® Q CHP Q CalRecycle Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name Inspected By Inspector <br /> Physical Address 0 1 A AA-z" Lw--/4- <br /> Inspection Date <br /> 6A a�®5- Time In _1 Time Out l <br /> O AM O AM <br /> Title <br /> Business Rep 3 1* PM Le -7 ® PM <br /> ��e, Operational Status Tire Type Business Role Storage Type <br /> 190 (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> Tire Count(Whole/PTE) , <br /> ® Active Q Passenger ® Generator ®Outdoor <br /> O Q Closed Q Altered <br /> GPS Latitude Q Hauler Indoor <br /> O Q Inactive ® Truck <br /> Longitude - Q Planned Q OTR Q End-Use Q Container <br /> Business Type(Fill all that apply) <br /> Q New Tire Dealer ®Auto Repair Q Trucking Fleet Q Government Q Retreader Q Dismantler Q Tire Derived Fuel <br /> Q 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 A HAULING AND MANIFEST REQUIREMENTS Q Notice Of Violation Q Extension <br /> Q Q PRC§42951 -Waste Tire Hauler Registration and Transport of Tires <br /> Q Q PRC§42953-Contracts with Registered Waste Tire Haulers. Compliance Deadline <br /> Q Q 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 CalRecyclea <br /> (Required for NOV or EXT <br /> Q Q <br /> 14 CCR§18459.2.1 -Submittal of Comprehensive Trip Logs within 90 days <br /> N <br /> Q Q 14 CCR§18459.3-Retention of Comprehensive Trip Logs for 3 years o <br /> Q Q 14 CCR§18460.2-Manifest System Requirements for Registered Waste Tire Haulers Q Referred/CalRecycle Enforcement <br /> W <br /> Q O 14 CCR§18461 -Manifest System.Requirements for Waste Tire End-Use Facilities -. <br /> Q O 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators ®In Compliance-No Violations o <br /> Q Q Other:§ <br /> Comments <br /> m� <br /> Inspection Form Included: O <br /> Comments Included: O <br /> Business Rep's Signature Phone Number I s c or' ig ture Phone Number <br /> 62081 <br /> INSTRUCTIONS ON BACK Correct:* Incorrect: g E X A M L 1 2 3 <br /> ® White Copy:CalRecycle Yellow Copy:Operator Pink Cop QT <br /> ® ■ <br />