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2 Waste Tire S%by & Inspection Report ispection Report Number <br /> CalRecycle State of California <br /> CalRecycle 181(Rev.10/10) Survey Form - Page 1 I1 - 1176 ` 23 <br /> Dept.of Resources Recycling and Recovery(CalRecycle) <br /> Part A-Survey _ BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- O ! D q Q - Inspection Type(Fill one) <br /> Site Suffix: k+ (� ® Routine Q Re-inspection Q Referral Q Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier: yL <br /> ct41 17ZCHP Q CalRecycle Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name I petted By Inspector <br /> Physical Address - © f <br /> �r�31�II-°(fI?ll�lc �CtiP_G�-rTN` <br /> :Z 373 S S S <br /> Inspection Date U <br /> rcf Ca I S 3,7- l CJ <br /> Time In Time Out <br /> Business Rep Title Q AM0 O AM <br /> Operational Status Tire Type Business Role Storage Type <br /> Tire Count (Whole/PTE) D (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> ® Active Q Passenger ® Generator ® Outdoor <br /> GPS Latitude O Q Closed Q Altered Q Hauler 0 Indoor <br /> O Q Inactive Q Truck <br /> Longitude - Q Planned A 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 ! Other <br /> fi cam.-Yv;� `IC(.{Kciv <br /> Part B - Inspection of Waste Tire Dealer, Generator, Hauler and End-Use Facility ENFORCEMENT STATUS <br /> V A THAULING AND MANIFEST REQUIREMENTS <br /> .......... _ _ Q 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 /> Q Q 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 <br /> Q Q 14 CCR§18459.2.1 -Submittal of Comprehensive Trip Logs within 90 days (Required for NOV or EXT) <br /> r <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 /> Q Q 14 CCR§18461 -Manifest System Requirements for Waste Tire End-Use Facilities W <br /> Q Q 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators ®In Compliance-No Violations o <br /> Q Other: <br /> Q § J <br /> Comments �.I <br /> it cP—'91-� iI,a• <br /> Inspection Form Included: Qi <br /> Comments Included: ® ;v � A' <br /> Bus! ep' i at_ure Phone Number Inspector's Signature Phone Number <br /> INSTRUCTIONS ON CK <br /> ( 3 62081 <br /> Correct: Incorrect: E X A 1 2 <br /> -- - --- <br /> White Copy:CalRecycle Yellow Copy:Operator Pink Co - <br />