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Waste Tire Sup vey & Inspection Report Inspection Report Number <br /> CalRec cle State of California — <br /> Y CalRecycle 181(Rev.10/10) Survey Form - Page 1 1 1230192 <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 - IInspection Type(Fill one) <br /> Site Suffix: 4Rouine QRe-inspection Q Referral Q <br /> Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier: 45ay� 'J > c,��� �� Q CHP Q CalRecycle Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name "�l Inspected By Inspector <br /> Physical Address M tN <br /> 1 Oa)o �kti• 'P.�• 1 <br /> L <br /> C� ��� Inspection Date + � / � z <br /> Time In Time Out <br /> Business Rep Title 1 ` b O AM © 0 AM <br /> ` 1 1 a PM is PM <br /> Operational Status Tire Type Business Role Storage Type <br /> Tire Count (Whole/PTE) u (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> r ' l <br /> 70 0 Active Q Passenger * Generator Q Outdoor <br /> O Q Closed Q Altered <br /> GPS Latitude _ Q Hauler Q Indoor <br /> O <br /> Q Inactive 0 Truck <br /> Longitude - Q Planned Q OTR Q End-Use 0 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 0 Other V-a-Away <br /> Part B - Inspection of Waste Tire Dealer, Generator, Hauler and End-Use Facility ENFORCEMENT STATUS <br /> V • A I HAULING AND MANIFEST REQUIREMENTS <br /> Q Notice Of Violation Q 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 /> Q Q PRC§42956-Registration/Decal in Vehicle <br /> Q O 14 CCR§18459-Responsible Entities Complying with Manifesting Requirements Date M / M / m <br /> Q 0 14 CCR§18459.1 -Tire Program ID Number from CalRecycle <br /> Q Q 14 CCR§18459.2.1 -Submittal of Comprehensive Trip Logs within 90 days (Required for NOV or EXE12 <br /> Q Q 14 CCR§18459.3-Retention of Comprehensive Trip Logs for 3 years <br /> 0 <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 u, <br /> Q O 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 /> Inspection Form Included: Q _ p <br /> Comments Included: <br /> Business Rep's Signature Phone Number Inspect is Signature Phone Number <br /> �-,( 62081 <br /> NJ <br /> INSTRUCTIONS ON BACK Correct: Incorrect: X EXAMPLE 1 2 3 <br /> White Copy:CalRecycle Yellow Copy:Operator Pink Copy:LEA <br />