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• <br /> Waste Tire Survey & Inspection Report -* inspection Report Number <br /> State of California <br /> CalRecycle I 1 _ 1210502 <br /> CalRecycle 181(Rev.10110) <br /> (Ca[ 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- I Inspection Type(Fill one) <br /> Site Suffix: 0 Routine 0 Re-inspection 0 Referral 0 Observation <br /> Local �- ) ]. If Referral,choose referral type(Fill one) <br /> Identifier: J U��j (�ur1'1� 0 CHP 0 CalRecycle 0 Complaint 0 Educational Visit 0 Other <br /> Business or Facility Name v 1 <br /> Inspected By Inspector <br /> Physical Address 3 q ' 0 l C <br /> J Inspection Date O <br /> �Gt1 t o Ci X153 l <br /> Time In Time Out <br /> Business Rep Title ` �j 0 AM j� O AM <br /> I I J ® PM V ® PM <br /> Operational Status Tire Type Business Role Storage Type <br /> Tire Count(Whole/PTE) (Fillone only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> 0 Active 0 Passenger ® Generator 0 Outdoor <br /> 0 Closed 0 Altered <br /> GPS Latitude 0 Hauler 0 Indoor <br /> C 0 Inactive 0 Truck <br /> Longitude - 0 Planned 0 OTR 0 End-Use • Container <br /> Business Type(Fill all that apply) <br /> 0 New Tire Dealer 0 Auto Repair 41 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 0 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 /> 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 PRC§42956-Registration/Decal in Vehicle <br /> 0 0 14 CCR§18459-Responsible Entities Complying with Manifesting Requirements Date m <br /> 0 0 14 CCR§18459.1 -Tire Program ID Number from CalRecycle <br /> 0 0 14 CCR§18459.2.1 -Submittal of Comprehensive Trip Logs within 90 days (Required for NOV or EXE N <br /> 0 0 14 CCR§16459.3-Retention of Comprehensive Trip Logs for 3 years o <br /> 0 0 14 CCR§18460.2-Manifest System Requirements for Registered Waste Tire Haulers 0 Referred/CalRecycle Enforcement <br /> 0 0 14 CCR§18461 -Manifest System Requirements for Waste Tire End-Use Facilities W <br /> 0 0 14 CCR§18462-Manifest System Requirements for Tire Dealers <br /> '(or Waste Tire Generators r In Compliance-No Violations o <br /> 0 0 Other:§ PR CSS �' �-1 — tY1�t�yr 'lNus}L' `iy� �uUIt �Ih'r,�' <br /> Comments \ i y <br /> i v�r�S�'� 11 i��QsuJ., <br /> Inspection Form Included: 0 / �,/ vvl 1 , a_ <br /> Comments Included:• 7y "L a <br /> Business Rep's Signature Phone Number Inspec 's Signature hone Number <br /> INSTRUCTIONS ON BACK Correct:* Incorrect: 7X7*7V71 E X A M L E 1 2 3 62081 <br /> ■ White Copy:CalRecycle Yellow Copy:Operator Pink Copy:L ® 0 <br />