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Waste Tire Su ey & Inspection Report inspection Report Number <br /> CalRecycle State of cle 181(R I 1 - 1177832 <br /> CalRecycle 181(Rev.10/10) Survey Form - Page 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- t'1 - © Inspection Type(Fill one) <br /> Site Suffix: i J 1 0 Routine 0 Re-inspection 0 Referral 0 Observation <br /> Local ` If Referral,choose referral type(Fill one) <br /> Identifier: Ckn 0(Al uA n 0 CHP 0 CalRecycle 0 Complaint 0 Educational Visit 0 Other <br /> Business or Facility Name Inspected By Inspector <br /> ui P� 4 Ce _ 3 - 1 b ► �s uta <br /> Physics ddr ss <br /> Inspection Date / V , 3 <br /> v _) <br /> Time In Time Out <br /> Business Rep Title � 2 O 0 AM 0 AM <br /> ,�j PM <br /> J B PM lJ <br /> �7� ►cn S'Vvicaj C00A. <br /> - Operational Status Tire Type Business Role Storage Type <br /> Tire Count (Whole/PTE) <br /> (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> 3 <br /> ® Active 0 Passenger ® Generator ® Outdoor <br /> O 0 Closed 0 Altered <br /> GPS Latitude 0 Hauler 0 Indoor <br /> 0 0 Inactive Q Truck <br /> Longitude - 0 Planned 40 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 IS Other FnfUli-S-M <br /> Part B- Inspection of Waste Tire Dealer, Generator, Hauler and End-Use Facility ENFORCEMENT STATUS <br /> V I A I HAULING AND MANIFEST REQUIREMENTS <br /> 0 Notice Of Violation 0 Extension <br /> 0 0 <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 T <br /> 0 0 14 CCR§18459-Responsible Entities Complying with Manifesting Requirements Date m / m / <br /> 0 0 14 CCR§18459.1 -Tire Program ID Number from CalRecycle <br /> (Required for NOV or EXE <br /> 0 0 N <br /> 14 CCR§18459.2.1 -Submittal of Comprehensive Trip Logs within 90 days a <br /> 0 14 CCR§18459.3-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 /> LU <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:§ l <br /> Comments <br /> V�v�S n o - <br /> Inspection Form Included: 0 <br /> Comments Included: 4Bu ' Phone s Rep's Signature Number Insp or's Signature Phone Number <br /> _ 62081 <br /> INSTRUCTIONS ON BACK Correct: Incorrect: � W EXAMPLE 1 2 3 <br /> White Copy:CalRecycle Yellow Copy:Operator Pink Copy:LEA <br />