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ection Report Number <br /> Waste Tire � .ey & Inspection Repo ns p p <br /> State of California <br /> CalRecycle I 1 - 1176730 <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- Inspection Type(Fill one) <br /> Z <br /> .Site Suffix: 3 © ® Routine Q Re-inspection Q Referral Q Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier: �(,�y�--7j� wa4414Q CHP Q CalRecycle Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name l! Inspected By Inspector <br /> Physical Address <br /> 12 <br /> Inspection Date j r / ti <br /> Time In ` Time Out <br /> Business Rep Title _ O AM Q AM <br /> 0 a 9 PM Q 3 ® PM <br /> 4117 r- Operational Status Tire Type Business Role Storage Type <br /> Tire Count (Whole/PTE) (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> 7� 0 Active Q Passenger ®Generator Q Outdoor <br /> O Q Closed Q Altered <br /> GPS Latitude Q Hauler Q Indoor <br /> O Q Inactive ® Truck <br /> Longitude - Q Planned 0 OTR Q End-Use Q Container <br /> Business Type Fill all that apply)( PP Y) <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 Q Other <br /> Part B - Inspection of Waste Tire Dealer, Generator, Hauler and End Use Facility ENFORCEMENT STATUS <br /> ----- ---- - — -- <br /> V A HAULING AND MANIFEST REQUIREMENTS <br /> -- --- --- -- -- -- - -- Q Notice Of Violation Q Extension <br /> Q Q PRC§42951 -Waste Tire Hauler Registration and Transport of Tires <br /> Q Q PRC§42953-Contracts with Registered Waste Tire Haulers. Compliance Deadline <br /> Q Q 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 /> (Required for NOV or EXE <br /> Q Q 14 CCR§18459.2.1 -Submittal of Comprehensive Trip Logs within 90 days N <br /> r <br /> Q Q 14 CCR§18459.3-Retention of Comprehensive Trip Logs for 3 years o <br /> i r <br /> Q Q 14 CCR§18460.2-Manifest System Requirements for Registered Waste Tire Haulers Q Referred/CalRecycle Enforcement <br /> 2 <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 /> 10101 Other:§ L* <br /> Comments <br /> r�1 a/Z� <br /> Inspection Form Included: Q ZOO Z�S Ze�`�S <br /> Comments Included: <br /> Business Re s Signature Phone Number Inspector's Signature Phone Number <br /> INSTRUCTIONS ON BACK [Correct: Incorrect. 62081 <br /> } (� E X A E 1111 <br /> 1 2 3 <br /> White Copy:CalRecycle Yellow Copy:Operator Pink Co V <br />