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Waste Tire Su. ✓ y & Inspection Repon I—section Report Number ■ <br /> State of California <br /> CalRecycle <br /> CalRecycle 181(Rev.10/10) <br /> (Cal Survey Form - Page 1 11 1210366 <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 t 5 O 0 - a 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: J f12� V r CG V n�t/ 0 CHP 0 CalRecycle 0 Complaint 0 Educational Visit 0 Other <br /> Business or Facility Name l Inspected By Inspector <br /> Physical Address <br /> /\—A Z o,,j -- - <br /> Inspection Date � � )? � <br /> S�oc��o� C 9S2o� <br /> Time In Time Out <br /> Business Rep Title I Z O •AM 0 AM <br /> '2 Z e PM <br /> / Q PM <br /> Dav\ 1�,C,\,.\ �lwln�. � cv:so� <br /> - ---- - — - - 16 Operational Status Tire Type Business Role Storage Type <br /> Tire Count (Whole/PTE) Z Q (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> • Active 0 Passenger 0 Generator ®Outdoor <br /> O 0 Closed 0 Altered <br /> GPS Latitude 0 Hauler 0 Indoor <br /> O 0 Inactive • Truck <br /> Longitude - 0 Planned 0 OTR 0 End-Use 18 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 0 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 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-Registration/Decal in Vehicle <br /> 00 14 CCR§18459-Responsible Entities Complying with Manifesting Requirements Date M MZ5 / M13; <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 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 /> Uj <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 0 In Compliance-No Violations o <br /> 0 1 0 1 Other:§ <br /> Comments ',->ASVQ Tory Iy'so-t-,o"t.' rN ACV,e Qin +-Lni S <br /> � <br /> Cl k.�t at Li ng W lX VZ O Tr <br /> c <br /> Inspection Form Incl01 Zuded: 0 0_�V-7 b, <br /> j <br /> � 00? <br /> q 32 <br /> Comments Included: <br /> Business Rep's Signature Phone Number Inspe or's Signature Phone Number <br /> �( <br /> INSTRUCTIONS ON BACK Correct: Incorrect: X � NV EXAMPLE 1112 3 62081 <br /> ■ White Copy:CalRecycle Yellow Copy:Operator Pink Copy:LEA © ■ <br />