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02 Waste Tire Survey <br /> & Inspection Re <br /> orflInspection Report Number <br /> State of California <br /> CalRecycle 181(Rev.10/10) <br /> Survey Form - Page 1 1 - 1230148 <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 /> O <br /> Site Suffix: ® Routine Q Re-inspection Q Referral Q Observation <br /> Local e— If Referral,choose referral type(Fill one) <br /> Identifier: SW\ J Oa,(/I IA%(-� �A&& k� Q CHP Q CalRecycle Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name 1 Inspected By Inspector <br /> �c�o <br /> Physil <br /> caAddress <br /> Inspection Date <br /> �co�cc�,, CA �t5a15 <br /> Time In Time Out <br /> Business Rep Title r �l AM 1 (' * AM <br /> I l U �J Q PM l 0 PM <br /> -- — 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 /> Q Active Q RUA <br /> nger Q Generator Q Outdoor <br /> ® Closed Q 'rnVl�� N! "I <br /> GPS Latitude Q Haurer� Q Indoor' <br /> Q Inactive Q Truck <br /> Longitude - Q Planned Q OTR Q End-Use Q 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 Q Other NIA <br /> A <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 /> 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 /> PRG§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§18459.2.1 -Submittal of Comprehensive Trip Logs within 90 days (Required for NOV or EXE N <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 Enforcement <br /> Lu <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 /> Q Q Other:§ <br /> Comments A to ►fir( 4..k� o,_-\_fjfl P�eS P� k �I'�J ��� _ <br /> ��j,S f l�c1�= N b-�� r <br /> S ��' lrv�s;fyss U� rl�]' Iacs ,'un� G�osc �� D <br /> Inspection Form Included: Q - <br /> Comments Included: Q --- - �� "�- <br /> Business Rep's Signature Phone Number nsp or's Signature Phone Number <br /> INSTRUCTIONS ON BACK Correct: Incorrect: EXAM E 1 2 3 62081 <br /> L <br /> White Copy:CalRecycle Yellow Copy:Operator Pink Copy: Ep <br />