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Waste Tire S ey & Inspection Reporonspection Report NumberState of ■ <br /> CalRecycle CalRecyclelifornia 181(Rev.10/10) T 1 <br /> Dept.of Resources Recycling and Recovery(CalRecycle) Survey Form - Page 1 11 - 1176676 <br /> Part A-Survey __ BLUE_ OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- _ Inspection Type(Fill one) <br /> Site Suffix: { l7 I 5 0 Routine 0 Re-inspection 0 Referral 0 Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier. sc" A 0 CHP 0 CalRecycle 0 Complaint 0 Educational Visit 0 Other <br /> Business or Facility Name ' - <br /> Inspected By Inspector <br /> Physical Address .3 �y 13Oe -Tj c1v <br /> I y 2epkH t" C+ - c� <br /> Inspection Date / 0 / ! r7 / f <br /> Time In Time Out <br /> Business Rep Title * AM ® AM <br /> {� p f Q PM O 0 QPM <br /> n 4, au»�rx - - �� 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 ® Outdoor <br /> Latitude O0 Closed 0 Altered <br /> O 0 Inactive ® 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 ® Other cow-buoli an 'd <br /> Part B - Inspection of Waste Tire Dealer, Generator, Hauler and End-Use Facility ENFORCEMENT STATUS <br /> V A HAULING AND MANIFEST REQUIREMENTS <br /> - - -- <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 EXE- 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 <br /> 0 1 0 1 Other:§ IS In Compliance-No Violations <br /> -- <br /> Comments <br /> Inspection Form Included: 0 V - <br /> Comments Included: ® <br /> Business Rep's agnature Phone Number nspector's Signature Phone Number <br /> INSTRUCTIONS ON BACK Correct: Incorrect: E X A M P E 2131 62081 <br /> White Copy:CalRecycle Yellow Copy:Operator J Pink Copy:L A <br />