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Waste Tire SAey & Inspection Reporonspection Report Number <br /> CalRecycle State of California <br /> CalRecycle 181(Rev.10/1o) Suntey Form - Pae 1 I1 - 1177746 <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 C q - Inspection Type(Fill one) <br /> Site Suffix: 1 7 1 ® Routine Q Re-inspection Q Referral Q Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier: %4_� )���y V C�mac / Q CHP Q CalRecycle Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name 4 \ !/ Inspected By Inspector <br /> Physic Address <br /> Inspection Date S / O `'1 <br /> Time In Time Out <br /> Business Rep Title Q O AM d O AM <br /> ® PM WPM <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 Q Passenger 0 Generator * Outdoor <br /> O Q Closed Q Altered <br /> GPS Latitude Q Hauler Q Indoor <br /> O Q Inactive 0 Truck <br /> Longitude - Q Planned Q OTR Q End-Use A Container <br /> Business Type(Fill all that apply) <br /> Q 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 Q Car Dealer Q Collection Q Crumb Rubber <br /> Q Service Station Q Hauler Q Agriculture Q Shredder 0 Other T'nA_SM0k( <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 <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 /> 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 orEXT) 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 /> 2 <br /> W <br /> Q Q 14 CCR§18461 -Manifest System Requirements for Waste Tire End-Use Facilities _ <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:§ a ` \ <br /> Comments Y,-,5V'e_ `-01 t 0 V\.e- cs'A �h�S—AMA& <br /> !Vy�p cx.��o,n,S p(' ✓�'P.A.� •C� -t- COy�eet'►'l <br /> Inspection Form Included: Q / 09 L <br /> +qv <br /> Comments Included: �-32$ <br /> Business Rep's Sign re Phone Number Inspe tor's Signature Phone Number <br /> INSTRUCTIONS ON BACK Correct:41 Incorrect: E X A M P L 'E 1112 3 62081 <br /> ® White Copy:CalRecycle Yellow Copy:Operator Pink Copy:LEA 0 <br />