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Waste Tire Survey & Inspection Report inspection Report Number M <br /> CalRecycle State of California <br /> - 1230424 CalRecycle 181(Rev.10/10) Survey Form - Page 1 1 <br /> Dept.of Resources Recycling and Recovery(CalRecycle) <br /> _ - BLUE OR BLACK INK PEN <br /> Part A-Survey <br /> Business Profile Inspection Details <br /> TPID- 6 / _ Inspection Type(Fill one) <br /> Site Suffix: �j O 0 Routine Q Re-inspection Q Referral Q Observation <br /> Local � If Referral,choose referral type(Fill one) <br /> Identifier: �0.� C,C, Y Q CHP Q CalRecycle Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name /( Inspected By Inspector <br /> Physic2l Address <br /> Inspection Date 1 O <br /> Time in Time Out <br /> Business Rep <br /> ll o We AM ®AM <br /> 3 QPM ` O 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 /> ' ' 7 Q Active Q Passenger Q Generator 0 Outdoor <br /> -- — O eo ' j <br /> CIPS Latitude Closed Q Ar <br /> • C�Hauler Q Indoor <br /> 0 Q Inactive Q TruL <br /> Longitude - Q End-Use Q Container <br /> Q Planned Q OTR <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 48 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 /> V A I 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 /> QQ 14 CCR§18459-Responsible Entities Complying with Manifesting Requirements Date m / FTI / m <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 E)C7) <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 <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:§ z <br /> Comments <br /> WC's �c�rJ'lp \j�O�Op�nS oft-2c�Sy� �O�C.2.�h <br /> t,ISL�+Ct_�_N• / �bS i YDS S �S YAC) 't'�.i.S 11�C.[Y�C'�O'n 1��C�`o-L'�/ l�� �OLCoIV\�C` <br /> CLC'OX,. <br /> Inspection Form Included: <br /> Comments Include ` O <br /> usiness Rep's Signature Phone Number Inspec or's Signature Phone Number <br /> INSTRUCTIONS ON BACK Correct:0 Incorrect: EXAMPLE 1 2 3 62081 <br /> MWhite Copy:CalRecycle Yellow Copy:Operator Pink Copy:LEA ® ■ <br />