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Waste Tire SAey & Inspection Reporkeinspection Report Number <br /> CalRecycle State of California I 1 - 1242162 <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- Ck aInspection Type(Fill one) <br /> Site Suffix: , 1 0 1 0 Routine Q Re-inspection Q Referral Q Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier: C, o v1� �V� O CHP Q CalRecycle Q Complaint Q Educational Visit O Other <br /> Business or Facility Name Inspected By Inspector <br /> Physical Address <br /> � <br /> Inspection Date , -7 vu.,,\,�,_ x. CA CIS t? Q -7 <br /> Time In Time Out <br /> Business Rep Title 1 * AM S e AM <br /> QPM � O QPM <br /> °`� ��`�� C Operational Status Tire Type Business Role Storage Type <br /> Tire Count(Whole/PTE) ' C (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> ,J `Active Passenger 0 Generator Outdoor <br /> Q Closed O Altered <br /> GPS Latitude Q Hauler Q Indoor <br /> O Q Inactive Truck <br /> Longitude - O Planned OTR O End-Use O 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 IS Other C V1Z.VH'CC,\ '�t�%Nzc_c 2 <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 Q Extension <br /> O O <br /> PRC§42951 -Waste Tire Hauler Registration and Transport of Tires <br /> O O PRC§42953-Contracts with Registered Waste Tire Haulers. Compliance Deadline <br /> PRC§42956-Registration/Decal in Vehicle <br /> O O 14 CCR§18459-Responsible Entities Complying with Manifesting Requirements Date m / m / m <br /> O O 14 CCR§18459.1 -Tire Program ID Number from CalRecycle <br /> O O 14 CCR§18459.2.1 -Submittal of Comprehensive Trip Logs within 90 days (Required for NOV or EXn N <br /> a <br /> O Q 14 CCR§18459.3-Retention of Comprehensive Trip Logs for 3 years <br /> O O 14 CCR§18460.2-Manifest System Requirements for Registered Waste Tire Haulers Q Referred/CalRecycle Enforcement <br /> O O 14 CCR§18461 -Manifest System Requirements for Waste Tire End-Use Facilities W <br /> O O 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators f In Compliance-No Violations o <br /> O O Other:§ <br /> Comments <br /> Inspection Form Included: QDD <br /> Comments Included: O J <br /> Bu ness Rep's Signature Phone Number Inspe toy's Signature Phone Number <br /> INSTRUCTIONS ON BACK Correct: incorrect: E X A M P L E 1112 3 62081 <br /> White Copy:CalRecycle Yellow Copy:Operator Pink Copy:LEA <br />