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Waste Tire Sue vey & Inspection Report Inspection Report Number ■ <br /> CalRecycle State of California <br /> CalRecycle 181(Rev.10/10) Survey Form - Page 1 I1 1229944 <br /> Dept.of Resources Recycling and Recovery(CalRecycle) <br /> part A- Survey BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- Inspection Inspection Type(Fill one) <br /> Site Suffix: I I* Routine Q Re-inspection Q Referral Q Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier: "�2�� �Q,, [l �.j�r 66 Q CHP Q CalRecycle Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name <br /> Inspected By Inspector <br /> Physical Address <br /> Inspection Date O Z <br /> 1 <br /> Time In Time Out <br /> Business Rep r _ Title l l uC> O AM -Z O AM <br /> * PM (/ � I ®PM <br /> Operational Status Tire Type Business Role Storage Type <br /> Tire Count(Whole/PTE) ` 4 r (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> 0 Active ® Passenger 0 Generator a Outdoor <br /> O Q Closed Altered <br /> GPS Latitude 0 Hauler Q Indoor <br /> 0 Q Inactive � Truck <br /> Longitude - End Use Q Container <br /> Q Planned OTR <br /> Business Type(Fill all that apply) <br /> Q New Tire Dealer Q Auto Repair Q Trucking Fleet • 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 <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 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 <br /> Q Q 14 CCR§18459.2.1 -Submittal of Comprehensive Trip Logs within 90 days (Required for NOV or E)C7) N <br /> a <br /> Q Q 14 CCR§18459.3-Retention of Comprehensive Trip Logs for 3 years o <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 0 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 , ` (�,w&_ 0A 2Op�' t,�-3ZE 1 <br /> Comments Included: 1J�•�J�, -1 lY (/V�/ 1 <br /> uslness ep's ignature �Phoneer Insp tor's Signature Phone Number <br /> INSTRUCTIONS ON BACK Correct:* IE X A Mj P LE I l 2 3 62081 <br /> ■ White Copy:CalRecycle Yellow Copy:Operator Pink Copy:LEA �� ■ <br />