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Waste Tire Sup dey & Inspection Report Inspection Report Number <br /> CalRecycle state of California — <br /> CalRecycle 181(Rev.10/10) Survey Form - Mage 1 11 1230448 <br /> Dept of Resources Recycling and Recovery(CalRecycle) <br /> Part A-Survey BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- G _ 1 Inspection Type(Fill one) <br /> Site Suffix: -! 1 10 Routine Q Re-inspection Q Referral Q Observation <br /> Local If Referral, <br /> choose referral type(Fill one) <br /> Identifier: J®,-.en �"y� � . � Q CHP Q CalRecycle Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name <br /> Inspected By Inspector <br /> Physical Address <br /> �C5® 1A.P" e, v'_ <br /> Inspection Date <br /> f�La" c o, �' S?3-7 <br /> Time In Time Out <br /> Business Rep TitleQh e AM 0 AM <br /> 1P,���S "� t \ • 30 0 PM ® � PM <br /> ®� <br /> 46 `� 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 /> 0 Active Q Passenger 0 Generator 0 Outdoor <br /> O Q Closed Q Altered- <br /> GPS Latitude Q Hauler I Q Indoor <br /> 0 Q Inactive 10 Truck Longitude - Q End Use Q Container <br /> Q Planned Q OTR <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 I* Other ��C 1. <br /> Part B - Inspection of Waste Tire Dealer, Generator, Hauler and End-Use Facility ENFORCEMENT STATUS <br /> V I A I HAULING AND MANIFEST REQUIREMENTS <br /> Q Q - Q Notice Of Violation Q Extension <br /> 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 m / m <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 EX ) N <br /> a <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 Q Other:§ - <br /> Comments Va \Z 2 �Y\ +LxzN <br /> �f_ t9Llo,, n <br /> Inspection Form Included: O <br /> Comments Included: <br /> iness Rep's Signature Phone Number Inspecto s Signature Phone Number <br /> INSTRUCTIONS BACK Correct:0 Incorrect: X EXAMPLE 1 2 3 62081 <br /> ® White Copy:CalRecycle Yellow Copy:Operator Pink Copy:LEA <br />