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Waste Tire Survey & Inspection Report Inspection Report Number i <br /> CalRec cle State of California <br /> Y CalRecycle 181(Rev.10110) Survey Form - Page 1 I1 1210180 <br /> Dept.of Resources Recycling and Recovery(CalRecycle) <br /> Part A-Survey <br /> _ BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- � t , h -7 _ � 1 I* Routine <br /> nspection Type(Fill one) <br /> Site Suffix: "1 v 1 0 Re-inspection 0 Referral 0 Observation <br /> Local � If Referral,choose referral type(Fill one) <br /> Identifier: Sa h J Da-1 V SY\ `�._ID 0 CHP 0 CalRecycle 0 Complaint 0 Educational Visit 0 Other <br /> Business or Facility Name Inspected By Inspector <br /> Physical Address <br /> Inspection Date '7 / 2 / 1 3 <br /> SG� � C G�2a <br /> Time In Time Out <br /> Business Rep Title 1 O 0 AM � S � 0 AM <br /> ` PM ce PM <br /> Operational Status Tire Type Business Role Storage Type <br /> (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> Tire Count(Whole/PTE) <br /> ® Active 0 Passenger @ Generator ® Outdoor <br /> 0 Closed 0 Altered <br /> GPS Latitude 0 Hauler 0 Indoor <br /> 0 0 Inactive Truck <br /> Longitude - 0 Planned ® OTR 0 End-Use 0 Container <br /> Business Type(Fill all that apply) <br /> 0 New Tire Dealer 0 Auto Repair 0 Trucking Fleet 0 Government 0 Retreader 0 Dismantler 0 Tire Derived Fuel <br /> 40 Used Tire Dealer 0 Auto Body 0 Car Dealer 0 Collection 0 Crumb Rubber <br /> Service Station 0 Hauler 0 Agriculture 0 Shredder 0 Other <br /> Part B - Inspection of Waste Tire Dealer, Generator, Hauler and End-Use Facility ENFORCEMENT STATUS <br /> V A HAULING AND MANIFEST REQUIREMENTS <br /> 0 0 - 0 Notice Of Violation 0 Extension <br /> PRC§42951 Waste Tire Hauler Registration and Transport of Tires <br /> 0 0 PRC§42953-Contracts with Registered Waste Tire Haulers. Compliance Deadline <br /> PRC§42956-Registration/Decal in Vehicle <br /> 0 0 14 CCR§18459-Responsible Entities Complying with Manifesting Requirements Date <br /> 0 0 14 CCR§18459.1 -Tire Program ID Number from CalRecycle <br /> 0 0 14 CCR§18459.2.1 -Submittal of Comprehensive Trip Logs within 90 days (Required for NOV or EXE N <br /> 0 0 14 CCR§18459.3-Retention of Comprehensive Trip Logs for 3 years <br /> 0 0 14 CCR§18460.2-Manifest System Requirements for Registered Waste Tire Haulers 0 Referred/CalRecycle Enforcement <br /> 2 <br /> Lu <br /> 0 0 14 CCR§18461 -Manifest System Requirements for Waste Tire End-Use Facilities <br /> 0 0 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators in Compliance-No Violations <br /> 0 0 Other:§ <br /> Comments <br /> C-5 _ <br /> '�5 a Cov�cc� <br /> Inspection Form Included: 0 <br /> 209-X66-303 r 2c,9-`�6g32 <br /> Comments Included: 0 <br /> Business Rep's Signature Phone Number Inspec is Signature Phone Number <br /> ' <br /> INSTRUCTIONS ON BACK Correct:0 Incorrect: ( E X A M P L E 1112 3 62081 <br /> ■ White Copy:CalRecycle Yellow Copy:Operator Pink Copy:LEA ® 0 <br />