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i <br /> Waste Tire Survey & Inspection Report <br /> Inspection Report Number <br /> CalRecycle State of California I 1 - 1226606 <br /> CalRecycle 181(Rev.10/10) Survey Form - Page 1 <br /> Dept of Resources Recycling and Recovery(CalRecycle) BLUE OR BLACK INK PEN <br /> Part A-Survey — - — -- <br /> Business Profile Inspection Details <br /> TPID- Inspection Type(Fill one) <br /> 1 <br /> Site Suffix: i l 5 l & Routine Q Re-inspection Q Referral Q Observation <br /> LocalIf Referral,choose referral type(Fill one) <br /> Identifier: '�� Q CHP Q CalRecycle Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name Inspected By Inspector <br /> C( A-r_Av� <br /> Physical Address <br /> Inspection Date <br /> Time In O� Time Out <br /> Business Rep Title 0 AM 1 ®AM <br /> Q PM t \ �J Q PM <br /> Vez, Operational Status Tire Type Business Role Storage Type <br /> 7 (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> c <br /> Tire Count(Whole/PTE) 3 ® Active Q Passenger ® Generator 0 Outdoor <br /> Q Closed Q Altered Q Hauler Q Indoor <br /> GPS Latitude , <br /> o Q Inactive O Truck <br /> Longitude - Q Planned ® OTR Q End-Use Q Container <br /> Business Type(Fill all that apply) <br /> Q New Tire Dealer Q Auto Repair Q Trucking Fleet ® 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 Other 414i,v, "iZlc, S �C <br /> Part B- Inspection of Waste Tire Dealer, Generator, Hauler and End-Use Facility ENFORCEMENT STATUS <br /> V A HAULING AND MANIFEST REQUIREMENTS -_ 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 <br /> Q Q 14 CCR§18459.1 -Tire Program ID Number from CalRecycle <br /> Q Q 14 CCR§ (Required for NOV or EXE N <br /> 18459.2.1 -Submittal of Comprehensive Trip Logs within 90 days a <br /> Q Q 14 CCR§18459.3-Retention of Comprehensive Trip Logs for 3 years <br /> Q Q 14 CCR§18460.2-Manifest System Requirements for Registered Waste Tire Haulers Q Referred/CalRecycle Enforcement2 <br /> LU <br /> Q Q 14 CCR§18461 -Manifest System Requirements for Waste Tire End-Use Facilities <br /> Q Q 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators In Compliance-No Violations o <br /> Q 1 Q Other:§ ------ <br /> Comments <br /> Inspection Form Included: Q - <br /> Comments Included: <br /> Business Rep's igna ure Phone Number *y: <br /> Number <br /> - 62081 <br /> INSTRUCTIONS ON BACK Correct:* Incorrect: � 5"Phone <br /> White Copy:CalRecycle Yellow Copy:Operator © ■ <br />