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r <br /> 03 Waste Tire Su. ✓ey & Inspection Report Inspection Report Number <br /> State of California <br /> CalRecycle <br /> CalRecycle181(Rev.10/10) 11 Form - Page 1 I1 - 1177647 <br /> Recycle) <br /> Dept.of Resources Recycling and Recovery(CalRecycle) Survey <br /> Part A-Survey BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- Inspection� � r Inspection Type(Fill one) <br /> �Site Suffix: I d ® Routine Q Re-inspection Q Referral Q Observation <br /> Local A �G If Referral,choose referral type(Fill one) <br /> Identifier: -�Ut v Q CHP Q CalRecycle Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name Inspected By Inspector <br /> Physical Address <br /> �,+/^ /,� Inspection Date <br /> VIA <br /> h'"�` v�y`-5-5�'7 Time In Time Out C <br /> Business Rep Title ®AM ® AM <br /> Tim p✓ ."i��. ( < d 0 O PM S Q PM <br /> N�S� JLY Operational Status .Tire Type Business Role Storage Type <br /> Tire Count (Whole/PTE) } (Fill bne only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> L 0 Active Q Passenger 0 Generator ® Outdoor <br /> o Q Closed Q Altered <br /> GPS Latitude Q Hauler Q Indoor <br /> O 0 Inactive 0 Truck <br /> Longitude - 0 Planned 0 OTR 0 End-Use Q Container <br /> Business Type(Fill all that apply) <br /> Q New Tire Dealer Q Auto Repair 0 Trucking Fleet Q Government 0 Retreader Q Dismantler Q Tire Derived Fuel <br /> Q Used Tire Dealer Q Auto Body Q Car Dealer Q Collection 0 Crumb Rubber <br /> Q Service Station Q Hauler Q Agriculture Q 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 /> Q Notice Of Violation Q Extension <br /> Q Q PRC§42951 -Waste Tire Hauler Registration and Transport of Tires <br /> Q 0 PRC§42953-Contracts with Registered Waste Tire Haulers. Compliance Deadline <br /> PRC§42956-Registration/Decal in Vehicle <br /> Q Q 14 CCR§18459-Responsible Entities Complying with Manifesting Requirements Date m <br /> Q Q 14 CCR§18459.1 -Tire Program ID Number from CalRecycle In <br /> 4 <br /> Q 0 14 CCR§18459.2.1 -Submittal of Comprehensive Trip Logs within 90 days (Required for NOV or EXT) <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 <br /> Inspection Form Included: Q f_2O9'— $"z.3--7/5 7 <br /> Comments Included: ® ?og-41,6 <br /> 73 <br /> s ess Rep's Signature Phone Number n to ' n ure Phone Number <br /> - - 62081 <br /> INSTRUCTIONS BACK Correct: Incorrect: E A P E 1 2 3 <br /> 0 White Copy:CalRecycle Yellow Copy:Operator Pink C y:L ® ■ <br />