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Waste Tire Survey & Inspection Report Inspection Report Number <br /> CalRec cle State of California <br /> Y CalRecycle 181(Rev.10/10) Survey Form - Page 1 11 1177660 <br /> Dept.of Resources Recycling and Recovery(CalRecycle) <br /> Part A-Survey -BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- Inspection Type(Fill one) <br /> Site Suffix: L j Ll If / Routine Q Re-inspection Q Referral Q Observation <br /> Local [ L, If Referral,choose referral type(Fill one) <br /> Identifier: (Vj c�t" C�gVy1 rt,/ Q CHP Q CalRecycle Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name 1 Inspected By Inspector <br /> Physical Address t <br /> JInspection Date <br /> 5�1) l <br /> Time In Time Out <br /> Business Rep Title _ O AM O AM <br /> OL ® PM Z ® PM <br /> - - - Operational Status Tire Type Business Role Storage Type <br /> Tire Count (Whole/PTE) -70 (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> f ' 10 Active ® Passenger ® Generator ®Outdoor <br /> O Q Closed Q Altered <br /> GPS Latitude Q Hauler Q Indoor <br /> O Q Inactive Q Truck <br /> Longitude - Q Planned ® OTR Q End-Use Q Container <br /> Business Type(Fill all that apply) <br /> Q New Tire Dealer Q 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 ® Other V10 <br /> v I&,," <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 � 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 a <br /> Q Q 14 CCR§18459.2.1 -Submittal of Comprehensive Trip Logs within 90 days (Required for NOV or EXE N <br /> _ a <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 /> Uj <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 Q Other: <br /> Comments <br /> N <br /> Inspection Form Included: O g 3! 00 <br /> Comments Included: <br /> Bu ' ep's Signature Phone Number a or's ignature Phone Number <br /> INSTRUCTIONS ON BACK Correct: ' Incorrect: E 1 2 3 62081 <br /> White Copy:CalRecycle Yellow Copy:Operator Pink Copy <br />