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Waste Tire Survey & Inspection Report Inspection Report Number ■ <br /> cle State of California <br /> CalRecycle Y CalRecycle 181(Rev.10/10) Survey Form - Page 1 I1 1196706 <br /> Dept.of Resources Recycling and Recovery(CalRecycle) <br /> Part A- Survey _ _ BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- � � 1 � C) � Inspection Type(Fill one) <br /> Site Suffix: Q Routine A Re-inspection Q Referral Q Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier: r WVr Q CHP Q CalRecycle Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name V <br /> Inspected By Inspector <br /> Physical Address <br /> � <br /> �J s Inspection Date 1 / r 1 / , 3 <br /> �r�C-� `�n�"'"\ Ch 062-3 Z 2 J` Time In Time Out <br /> Business Rep Title ' 1 ^ AM 1 ` C) If AM <br /> L QPM l O PM <br /> Operational Status Tire Type Business Role Storage Type <br /> Tire Count(WholPTE <br /> (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> 2 <br /> 0 Active 0 Passenger 0 Generator 0 Outdoor <br /> Q Closed Q Altered <br /> GPS Latitude Q Hauler Q Indoor <br /> O Q Inactive 0 Truck <br /> Longitude - Q Planned 4D 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 0 Other <br /> V� vY�h� l <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 <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 /> PRC§42956-Registration/Decal in Vehicle <br /> Q Q 14 CCR§18459-Responsible Entities Complying with Manifesting Requirements Date m / m / m <br /> Q Q 14 CCR§18459.1 -Tire Program ID Number from CalRecycle 9 <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 Lo <br /> 0 <br /> Q Q 14 CCR§18460.2-Manifest System Requirements for Registered Waste Tire Haulers Q Referred/CalRecycle Enforcement <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 <br /> in Compliance-No Violations o <br /> Q Q Other:§ \` <br /> CommentsQ,_\�Q� Li 0 _� C' <br /> Inspection Form Included: _ L4 2Z <br /> Comments Included: �9�ypp—�7�0 <br /> Business ep s Signature Phone Number Inspector's Signature Phone Number <br /> �,( <br /> INSTRUCTIONS ON BACK [Correct:0 Incorrect: NJ EXAMPLE 1 2 3 62081 <br /> White Copy:CalRecycle Yellow Copy:Operator Pink Copy:LEA © 0 <br />