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Waste Tire Survey & Inspection Report inspection Report Number <br /> State of California <br /> CalRecycle T ■ <br /> CalRecycle 181(Rev. (CalRecycle) <br /> Survey Form - Page 1 1 1226522 <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 Type(Fill one) <br /> Site Suffix: ( 6 g C ® Routine 0 Re-inspection 0 Referral 0 Observation <br /> Local �� ���� �� � If Referral,choose referral type(Fill one) <br /> Identifier: 0 CHP 0 CalRecycle 0 Complaint 0 Educational Visit 0 Other <br /> Business oor+�Facility Name Inspected By Inspector <br /> �J`'r r— <br /> Physical Address) To I <br /> Inspection Date / ^ J� / t 1 <br /> V L a& C z-� �� i Time In Time Out <br /> Business Rep Title Q AM Q AM <br /> t � O 0 PM � L � ® PM <br /> �0"avt Dr lmyrG`. ©WNer <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 /> r ' 1„/ 0 Active <br /> o Passenger g ® Generator 0 Outdoor <br /> GPS Latitude O 0 Closed0 Altered <br /> 0 Hauler ® Indoor <br /> O 0 Inactive 0 Truck <br /> LongitudeQ Planned 0 OTR End-Use 0- Container <br /> Business Type(Fill all that apply) <br /> New Tire Dealer 0 Auto Repair 0 Trucking Fleet 0 Government 0 Retreader 0 Dismantler 0 Tire Derived Fuel <br /> 0 Used Tire Dealer 0 Auto Body 0 Car Dealer 0 Collection 0 Crumb Rubber <br /> 0 Service Station 0 Hauler 0 Agriculture 0 Shredder 0 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 /> 0 0 PRC§42951 -Waste Tire Hauler Registration and Transport of Tires 0 Notice Of Violation 0 Extension <br /> 0 0 PRC§42953-Contracts with Registered Waste Tire Haulers. Compliance Deadline <br /> 0 0 PRC§42956-Registration/Decal in Vehicle <br /> 0 0 14 CCR§18459-Responsible Entities Complying with Manifesting Requirements Date <br /> 0 0 14 CCR§18459.1 -Tire Program ID Number from CalRecycle <br /> 0 0 14 CCR§18459.2.1 -Submittal of Comprehensive Trip Logs within 90 days (Required for NOV or EX7J N <br /> r, <br /> 0 0 14 CCR§18459.3-Retention of Comprehensive Trip Logs for 3 years <br /> 0 0 14 CCR§18460.2-Manifest System Requirements for Registered Waste Tire Haulers 0 Referred/CalRecycle Enforcement <br /> 0 0 14 CCR§18461 -Manifest System Requirements for Waste Tire End-Use Facilities u, <br /> 0 0 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators <br /> In Compliance-No Violations o <br /> 0 0 Other:§ <br /> Comments <br /> Inspection Form Included: 0 <br /> Comments Included: <br /> Bus e s Rep's Signature _ Phone Number _ 1 is i ature Phone Number <br /> E X PZ+f <br /> 2 3 s2os�-- - <br /> INSTRUCTIONS ON BACK Correct: Incorrect: I� <br /> ■ White Copy:CalRecycle Yellow Copy:Operator Pink Copy: ■ <br />