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Waste Tire Si e & Inspection Re orte Inspection Report Number <br /> CalRecycle State of California Y <br /> Y CalRecycle 181(Rev.10/10) Survey Form - Page 1 I1 - 1244952 <br /> Dept.of Resources Recycling and Recovery(CalRecycle) <br /> Part A- Survey BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- / � �^ ' Inspection Type(Fill one) <br /> O <br /> Site Suffix: f l (Q LAlJ 0 Routine Q Re-inspection Q Referral Q Observation <br /> Local �' , �^ If Referral,choose referral type(Fill one) <br /> Identifier: S 4(1 JC`7u.� l,(,n CIA n ' V 1 Q CHP Q CalRecycle Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name <br /> A <br /> ( 1 - L Inspected By Inspector <br /> A <br /> 0 ��� (�T S1 l o WCC()r� 3 ' 1 <br /> Physical Address _ CS Zo Ia <br /> C Zti2, Inspection Date / 1 <br /> Time In Time Out <br /> Business Rep TTitle , 5 O AM C� (3 O AM <br /> l�cnU. <br /> Q- Ln1 C— �gc�sd Servict fnunu 0 PM o` v 0 PM <br /> 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 /> ® Active ® Passenger ® Generator Q Outdoor <br /> Q Closed Q Altered <br /> GPS Latitude 0 Hauler ® Indoor <br /> O Q Inactive Q Truck <br /> Longitude — O Planned O OTR O End-Use Q Container <br /> Business Type(Fill all that apply) <br /> ®New Tire Dealer Q Auto Repair Q Trucking Fleet Q Government Q Retreader Q Dismantler Q Tire Derived Fuel <br /> Q Used Tire Dealer Q Auto Body A Car Dealer Q Collection Q Crumb Rubber <br /> Q Service Station Q Hauler Q Agriculture Q Shredder Q 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 /> O O <br /> PRC§42951 -Waste Tire Hauler Registration and Transport of Tires <br /> 0 O PRC§42953-Contracts with Registered Waste Tire Haulers. Compliance Deadline <br /> 0 O PRC§42956-Registration/Decal in Vehicle <br /> Q Q 14 CCR§18459-Responsible Entities Complying with Manifesting Requirements Date m / m <br /> O 0 14 CCR§18459.1 -Tire Program ID Number from CalRecycle N <br /> O O 14 CCR§18459.2.1 -Submittal of Comprehensive Trip Logs within 90 days (Required for NOV or EX7) N <br /> O 0 14 CCR§18459.3-Retention of Comprehensive Trip Logs for 3 years <br /> O Q 14 CCR§18460.2-Manifest System Requirements for Registered Waste Tire Haulers Q Referred/CalRecycle Enforcement <br /> O Q 14 CCR§18461 -Manifest System Requirements for Waste Tire End-Use Facilities W <br /> O 0 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators ®In Compliance-No Violations o <br /> O 0 Other:§ <br /> Comments n hj 1— LL !� _ l- r , <br /> Q � ,nS'� A Ic. \nSouTlftiy`�-�I 1 -�' L 01/& Q- My_) ` +� a <br /> N� 'V"0"Pn'_ OJ cAlt,"kt) <br /> Inspection Form Included: O <br /> Comments Included: <br /> s ep's Signature Phone Number llnsp7tor's Signature Phone Number <br /> INSTRUCTIONS O BACK [Correct:0 Incorrect: EXAMPLE 1 2 3 62081 <br /> ■ White Copy:CalRecycle Yellow Copy:Operator Pink Copy:L A © ■ <br />