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f r,APO 'r�r. T -• r%'L�:�++. i �F 1_91l ./rd=�trrt%E� <br /> frl.! � 0 Y �'. :::::.:�.. _ .. ._.._ ... .r_._•.,.r_s._ <br /> M Waste Tire Survey & Inspection Report Inspection Report Number ■ <br /> CalRecycle State of California I 1 - 1226578 <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 /> ------ - ——-- Inspection Details <br /> Business Profile — <br /> TPID- _ Inspection Type(Fill one) <br /> Site Suffix: S _ 0 Routine Q Re-inspection Q Referral Q Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier: V` Q CHP Q CalRecycle Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name Inspected By Inspector <br /> Physical Acu <br /> � n �{ Inspection Date j o / I 25 ) <br /> (.A `5a i� Time In lJ Time Out t <br /> O AM <br /> Business Rep Title O AM <br /> oZ CQ C> O PM J ® PM <br /> 1A WGly 6k CLykc�s' <br /> ��� �C ✓ 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) �. ® Active O Passenger ® Generator O Outdoor <br /> Q Closed Q Altered <br /> Latitude Q Hauler Q Indoor <br /> GPS � 0 Q Inactive Q Truck <br /> Longitude - Q Planned Q OTR Q End-Use Q Container <br /> Business Type(Fill all that apply) <br /> ® New Tire Dealer ® Auto Repair Q Trucking Fleet Q Government Q Retreader Q Dismantler Q Tire Derived Fuel <br /> Q Used Tire Dealer Q Auto Body ® Car Dealer Q Collection Q Crumb Rubber <br /> Q Service Station Q Hauler Q Agriculture Q Shredder Q Other <br /> Part B - Inspection of Waste Tire Dealer, Generator, Hauler and End-Use Facility ENFORCEMENT STATUS <br /> FV 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 m m <br /> Q Q 14 CCR§18459.1 -Tire Program ID Number from CalRecycle (Required for NOV or EXE N <br /> Q Q 14 CCR§18459.2.1 -Submittal of Comprehensive Trip Logs within 90 days <br /> Q Q 14 CCR§18459.3-Retention of Comprehensive Trip Logs for 3 years <br /> Q Q Q Referred/CalRecycle Enforcement <br /> 14 CCR§18460.2-Manifest System Requirements for Registered Waste Tire Haulers u, <br /> Q Q 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 /> Inspection Form Included: Q .i / (2u) <br /> 6 <br /> Comments Included: <br /> in6ss Rep's Signature _Phone Number I or' gnature Phone Number <br /> 62081 <br /> INSTRUCTIONS ON BACK Correct:40 Incorrect: E X <br /> Pink Co A ■ <br /> White Copy:CalRecycle Yellow Copy:Operator © <br /> ■ <br />