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Waste Tire Su. vey & Inspection Report Inspection Report Number ■ <br /> CalRecycle State of cle 181(R I 1 - 1230356 <br /> CalRecycle 181(Rev.10/10) Survey Form -Page 1 <br /> Dept of Resources Recycling and Recovery(CalRecycle) <br /> Part A-Survey BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- ' 7 3 ' _ I Inspection Type(Fill one) <br /> Site Suffix: 0 Routine 0 Re-inspection 0 Referral 0 Observation <br /> Local r If Referral,choose referral type(Fill one) <br /> Identifier: 50.r J b; Ca v y\ 0 CHP 0 CalRecycle 0 Complaint 0 Educational Visit 0 Other <br /> Business or Facility Name Inspected By Inspector <br /> lZ Y1\ <br /> Physical Address <br /> YInspection Date <br /> Time In Time Out <br /> Business RepT Title O AM O AM <br /> 6 PM O d PM <br /> Operational Status Tire Type Business Role Storage Type <br /> Tire Count (W hole/PTE) (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> 0 Active 0 Pa/ssseepger 0 Generator 0 Outdoor <br /> O &Closed 0 Alfer�i' lb 1er � <br /> GPS Latitude 0 Hauler �ndoor <br /> O 0 Inactive 0 Truck <br /> Longitude - 0 Planned 0 OTR 0 End-Use 0 Container <br /> Business Type(Fill all that apply) <br /> 0 New Tire Dealer 0 Auto Repair 0 Trucking Fleet 0 Government 0 Retreader 0 Dismantler 0 Tire Derived Fuel <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 , Other 5k4ftA_ �t ez_ pi�f'c,6�1 <br /> Part B - Inspection of Waste Tire Dealer, Generator, Hauler and End-Use Facility ENFORCEMENT STATUS <br /> VI A I HAULING AND MANIFEST REQUIREMENTS <br /> 0 0 - 0 Notice Of Violation 0 Extension <br /> 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 PRC§42956-Registration/Decal in Vehicle <br /> 0 0 14 CCR§18459-Responsible Entities Complying with Manifesting Requirements Date M / M / m <br /> 0 0 14 CCR§18459.1 -Tire Program ID Number from CalRecycle j <br /> 0 0 14 CCR§18459.2.1 -Submittal of Comprehensive Trip Logs within 90 days (Required for NOV or EXT) <br /> 0 0 14 CCR§18459.3-Retention of Comprehensive Trip Logs for 3 years <br /> 0 0 14 CCR§18460.2-Manifest System Requirements for Registered Waste Tire Haulers 0 Referred/CalRecycle Enforcement <br /> w <br /> W <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 o <br /> 0 0 Other:§ i <br /> Comments R_�•�ne o T, y" kzcLS_ ►�4- <br /> 6t) <br /> tP -tft�Z) 1 5 4731372 -al, <br /> Inspection Form Included: 0 /Z„d)Q .1( ')/� <br /> �&e �O�ryt qr— 2� <br /> Comments Included: 0 J:)sines Reps Signature f `Phone Number -Inspec�nature Phone Number <br /> �-,( <br /> INSTRUCTIONS ON BACK Correct: Incorrect: M � NJ E X A M P L E 1 2 3 62081 <br /> ■ White Copy:CalRecycle Yellow Copy:Operator Pink Copy:LEA ® ■ <br />