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00 Inspection Report Number <br /> Waste Tire Survey & Inspection Repo" 0 <br /> CalRecycle State of California 11 - 1245160 <br /> CalRecycle 181(Rev.10/10) Survey Form - Page 1 <br /> Dept.of Resources Recycling and Recovery(CalRecycle) BLUE OR BLACK INK PEN <br /> Part A- Survey <br /> Business Profile Inspection Details <br /> TPID- Type <br /> Inspection Type(Fill one)Site Suffix: 9 9 <br /> Routine 0 Re-inspection 0 Referral 0 Observation <br /> Local4If Referral,choose referral type(Fill one) Visit 0 Other <br /> Identifier. �� ul 0 CHP 0 CalRecycle 0 Complaint 0 Educational <br /> Business or-Facility Name Inspected By Inspector <br /> Physical Address <br /> Inspection Date o 2- / -5 <br /> Time In Time Out <br /> Title Z AM C- AM <br /> Business Rep eK Ty�s 0 0 PM il QPM <br /> �05 Operational Status Tire Type Business Role Storage Type <br /> Fill one only) (Fill all that apply') (Fill all that apply) (Fill all that apply) <br /> So age Typ <br /> ( all that <br /> 0 Outdoor <br /> Tire Count 61,& TE) 40 Active 0 Passenger Generator <br /> 7 <br /> 0 0 Closed 0 Altered 0 Hauler 0 Indoor <br /> GPS Latitude 0 0 inactive * Truck 0 End-use 0 container <br /> Longitude - 0 Planned 0 OTR <br /> Business Type(Fill all that apply) 0 Dismantler 0 Tire Derived Fuel <br /> 0 New Tire Dealer 41Auto Repair 0 Trucking Fleet 0 Government 0 Retre der <br /> 0 used 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 /> ENFORCEMENT <br /> STATUS <br /> V A HAULING AND MANIFEST REQUIREMENTS 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 0 PRC§42956-Registration/Decal in Vehicle m / m / m <br /> 0 0 14 CCR§18459-Responsible Entities Complying with Manifesting Requirements Date <br /> 0 0 14 CCR§18459.1 -Tire Program ID Number from CalRecycle <br /> (Required for NOV or EXT) C? <br /> 0 0 14 CCR§18459.2.1 -Submittal of Comprehensive Trip Logs within 90 days <br /> 0 0 14 CCR§18459.3-Retention of Comprehensive Trip Logs for 3 years <br /> 0 Referred/CalRecycle Enforcement <br /> 0 0 14 CCR§18460.2-Manifest System Requirements for Registered Waste Tire Haulers 2 <br /> Lu <br /> 0 0 14 CCR§18461 -Manifest System Requirements for Waste Tire End-Use Facilities <br /> 0 0 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators •in Compliance-No Violations <br /> .0 . 0 Other:§ <br /> Comments <br /> Inspection Form Included: 0 &* <br /> Comments Included: S Ll 7 Inspe tor's igna e Phone Number j <br /> Busi Is Signature Phone Number 62081 <br /> Correct:0 Incorrect: EXAMPLE 1 2 3 <br /> INSTRUCTIONS ON BACK N <br /> ■ White Copy:CalRecycle Yellow Copy:Operator Pink Copy:LEA <br />