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Waste Tire Survey & Inspection Report Inspection Report Number <br /> ■ State of California i <br /> CalRecycle CalRecycle 181(Rev.10/10) Survey Form - Page 1 I1 - 11 l 6 738 <br /> Dept.of Resources Recycling and Recovery(CalRecycle) <br /> Part A- Survey - BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- f C, \ _ I Inspection Type(Fill one) <br /> Site Suffix: 1 `O b O ` 0 Routine Q Re-inspection Q Referral Q Observation <br /> Local -\' / 1 If Referral,choose referral type(Fill one) <br /> Identifier: S�, ) �J oc.'j '1f\ (_01A Q CHP Q CalRecycle Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name Inspected By Inspector <br /> 0,uik�,�� 'T1 <br /> Physical Address <br /> Inspection Date a <br /> Time In Time Out <br /> Business Rep Title ® AM 0 AM <br /> PM ` O ® PM <br /> - - - - Operational Status Tire Type Business Role Storage Type <br /> ,cJ <br /> Tire Count (Whole/PTE) (Fill one only) (Fill ail that apply) (Fill all that apply) (Fill all that apply) <br /> j(�' <br /> f ' Q Active Q Passenger Q Generator Q Outdoor <br /> - -- -- o NAVA NIA N/A <br /> GPS Latitude 41 Closed Q Altere Q Hauler Q Indoor <br /> o 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 /> 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 /> Q Q PRC§42956-Registration/Decal in Vehicle <br /> Q O 14 CCR§18459-Responsible Entities Complying with Manifesting Requirements Date <br /> M / m / m <br /> Q O 14 CCR§18459.1 -Tire Program ID Number from CalRecycle <br /> Q O 14 CCR§18459.2.1 -Submittal of Comprehensive Trip Logs within 90 days (Required for NOV or EXE N <br /> a <br /> Q Q 14 CCR§18459.3-Retention of Comprehensive Trip Logs for 3 years o <br /> Q O 14 CCR§18460.2-Manifest System Requirements for Registered Waste Tire Haulers Q Referred/CalRecycle Enforcement <br /> Q O 14 CCR§18461 -Manifest System Requirements for Waste Tire End-Use Facilities <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 /> e. <br /> us haj\ C.. bnu) sh Jev0 1-1 oLo96-01 . doxic ;S-k�v- <br /> Inspection Form�nc <br /> ncluded: Q 1-7~ <br /> Comments luded: Q Number <br /> _ Business Rep's Signature Phone Number Inspe is Signature Phone Number <br /> 62081 <br /> INSTRUCTIONS ON BACK Correct:• Incorrect: E X A M P L E 1 2 3 <br /> White Copy:CalRecycle Yellow Copy:Operator Pink Copy:LEA ■ <br />