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Waste Tire Survey & Inspection Report Inspection Report Number <br /> CalRec cle State of California <br /> Y CalRecycle 181(Rev.10/10) Survey Form - Page 1 I1 - 1210557 <br /> Dept.of Resources Recycling and Recovery(CalRecycle) <br /> Survey <br /> -Survey BLUE OR BLACK INK PEN <br /> ness Profile Inspection Details <br /> TPID- Inspection Type(Fill one) <br /> Site Suffix: 0 Routine 0 Re-inspection 0 Referral 0 Observation <br /> Local l If Referral,choose referral type(Fill one) <br /> Identifier: � t�lYl LCy �I y 0 CHP 0 CalRecycle 0 Complaint 0 Educational Visit 0 Other <br /> Business or Facility Name Inspected By Inspector <br /> Physical Address <br /> /L 3'(!0 <br /> Inspection Date <br /> v <br /> CA ?sa-vim ti 1 3 <br /> Time In Time Out <br /> Business Rep Title AM ®AM <br /> { , / V .5 '5 O PM j 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 /> 0 Active 0 Passenger Generator 0 Outdoor <br /> Latitude O ® Closed 0 Altered N/ <br /> GPS 0 Hauler 0 Indoor <br /> 0 0 Inactive 0 Truck <br /> Longitude - 0 Planned ® OTR 0 End-Use 0 Container <br /> P—driess Type(Fill all that apply) 1 Trr-t <br /> Jew Tire Dealer 0 Auto Repair 0 Trucking Fleet 0 Government 0 Retreader 0 Dismantler 0 Tire Derived Fuel <br /> V Used Tire Dealer 0 Auto Body 0 Car Dealer 0 Collection 0 Crumb Rubber <br /> 0 Service Station 0 Hauler 0 Agriculture 0 Shredder I$ 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 Notice Of Violation 0 Extension <br /> 0 0 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-Registration/Decal in Vehicle <br /> 00 14 CCR§18459-Responsible Entities Complying with Manifesting Requirements Date m / FU / 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 EXI) n <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 1 Other:§ <br /> Comments <br /> ,c), 1 <br /> 4,vz N AJL'Z 4-jiq.- r�rL �,*,wwT� L►J / I ES c cq <br /> inspection Form Included: 0 <br /> Comments Included: 0 - <br /> Business Rep's Signat re Phone Number Iseo Signature Phone Number <br /> INSTRUCTIONS ON BACK Correct: Incorrect: E X I A IMI PL 1 12131 62081 <br /> White Copy:CalRecycle Yellow Copy:Operator Pink Copy: <br />