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Waste Tire SUF vey & Inspection Report Inspection Report Number ■ <br /> CalRec cle State of California — <br /> Y CalRecycle 181(Rev.10/10) Survey Form - Page 1 I1 1245346 <br /> Dept.of Resources Recycling and Recovery(CalRecycle) <br /> Sart A-Survey BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- O _ � 1 Inspection Type(Fill one) <br /> Site Suffix: ` ` 11 I* Routine Q Re-inspection Q Referral Q Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier: h YO0-1�: r CdvV Q CHP Q CalRecycle Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name �( Inspected By Inspector <br /> �c 0 cc' - L 0 1 A/v ki <br /> Physical Address <br /> "too S� � <br /> � �� � CJ`�� Inspection Date (01 / O I / - , s <br /> Time In Time Out <br /> Business Rep Title \ O PM 0 AM <br /> A(I Or 1 V J 46 PM <br /> "� Operational Status Tire Type Business Role Storage Type <br /> Tire Count (Whole/PTE) 2 <br /> (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> � � � <br /> o Active Q Passenger •Generator 40 Outdoor <br /> O Q Closed Q Altered <br /> GPS Latitude Q Hauler Q Indoor <br /> O Q Inactive 0 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 0 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 <br /> Part B - Inspection of Waste Tire Dealer, Generator, Hauler and End-Use Facility ENFORCEMENT STATUS <br /> V A HAULING AND MANIFEST REQUIREMENTS <br /> 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 /> PRC§42956-Registration/Decal in Vehicle <br /> Q Q 14 CCR§18459-Responsible Entities Complying with Manifesting Requirements Date <br /> Q Q 14 CCR§18459.1 -Tire Program ID Number from CalRecycle I I <br /> Q Q 14 CCR§18459.2.1 -Submittal of Comprehensive Trip Logs within 90 days (Required for NOV or EXE N <br /> a <br /> 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 /> W <br /> Q Q 14 CCR§18461 -Manifest System Requirements for Waste Tire End-Use Facilities <br /> Q Q 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators Q In Compliance-No Violations o <br /> Q Q Other:§ \ }� <br /> Comments Y� 4 I <br /> t� �� cuw� vkmn'"� <br /> 4; s P " <br /> Inspection Form Included: Q 6 <br /> 16� U-P>'OLf -G�62-32 <br /> Comments Included: ® / <br /> B Si s�Re�Signature Phone Number Inspeor's Signature Phone Number <br /> INSTRUCTIONS ON BACK Correct:I. Incorrect: EXAMPLE 1 2 3 62081 <br /> ■ White Copy:CalRecycle Yellow Copy:Operator Pink Copy:LFA ■ <br />