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Waste Tire Survey & Inspection Report Inspection Report Number <br /> cle State of California <br /> CalRecycle — <br /> Y CalRecycle 181(Rev.10/10) Survey Form - Page 1 I1 1245282 <br /> Dept.of Resources Recycling and Recovery(CalRecycle) <br /> Part A-Survey BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- I � i � � � � � � � Inspection Type(Fill one) <br /> Site Suffix: * Routine 0 Re-inspection 0 Referral 0 Observation <br /> Local , \_ If Referral,choose referral type(Fill one) <br /> Identifier: n ��1� -� 0 CHP 0 CalRecycle 0 Complaint 0 Educational Visit 0 Other <br /> Business or Facility Name Inspected By Inspector <br /> Physical Address ftX 1J�, f <br /> L VI" <br /> {, /+— 47 Inspection Date <br /> Time In Time Out <br /> Business Rep Title 1 z. ,s� 0 AM 0 AM <br /> ® PM ` PM <br /> b <br /> Operational Status Tire Type Business Role Storage Type <br /> Tire Count ho /PTE) (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> f Active 0 Passenger • Generator 0 Outdpor <br /> O 0 Closed 0 Altered "011� <br /> GPS Latitude 0 Hauler 0 Indoor <br /> 0 0 Inactive 0 Truck <br /> Longitude — 0 Planned 0 OTR 0 End-Use 0 Container <br /> Business Type(Fill all that apply) <br /> 0 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 4D Other L) <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 Notice Of Violation 0 Extension <br /> 0 0 <br /> PRC§42951 -Waste Tire Hauler Registration and Transport of Tires <br /> 0 0 PRC§42953-Contracts with Registered Waste Tire Haulers. Compliance Deadline <br /> PRC§42956-Regj�tration/Decal in Vehicle <br /> 0 0 14 CCR§18459-Responsible Entities Complying with Manifesting Requirements Date m / m / m <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 EX7) N <br /> a <br /> 0 0 14 CCR§18459.3-Retention of Comprehensive Trip Logs for 3 years o <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 w <br /> 0 0 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators .In Compliance-No Violations o <br /> 0 0 Other:§ <br /> Comments �j; <br /> Inspection FormIncluded: 0 Q-01) 1!I&b <br /> at jL c �0�'i 4(.Q v-Z6 3- <br /> Comments Included: <br /> Business Rep's Signature Phone Number Anpector's Si Phone Number <br /> INSTRUCTIONS ON BACK Correct: Incorrect: 62081 EXAMPLE 123 <br /> White Copy:CalRecycle Yellow Copy:Operator Pink Copy:LEA <br />