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Waste Tire Su. Bey & Inspection Report .iispection Report Number ■ <br /> CalRecycle State of California <br /> CalRecycle 181(Rev.10/10) 5unjey Fora - gage 1 11 - 1230385 <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- f Inspection Type(Fill one) <br /> Site Suffix: 1 5 3 3 t0 �/ © 1 49 Routine Q Re-inspection Q Referral Q Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier. ��4� �'^ Q CHP Q CalRecycle Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name a s� Inspected By Inspector <br /> Physical Adss <br /> Inspection Date <br /> 52 <br /> ON-\ Time In Time Out <br /> Business Rep Titleh O AM O AM <br /> , • V ® PM i * PM <br /> Operational Status Tire Type Business Role Storage Type <br /> Tire Count (Whole/PTE) ,.j (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> ® Active I& Passenger ® Generator Q u tjP9 r <br /> o Q <br /> GPS Latitude Q Closed Q Altered , <br /> 0 Q Inactive Q Truck Q Hauler Indoor <br /> Longitude - Q Planned 40 OTR Q End-Use Q 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 Derives(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 ® Other UA Lz <br /> Part B- Inspection of Waste Tire Dealer, Generator, Hauler and End-Use Facility ENFORCEMENT STATUS <br /> V 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 / m <br /> Q 0 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 EXT) N <br /> r <br /> Q O 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 I <br /> Uj <br /> W <br /> Q Q 14 CCR§18461 -Manifest System Requirements for Waste Tire End-Use Facilities _- <br /> Q O 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators In Compliance-No Violations o <br /> Q Q Other:§ <br /> Comments c�pS. he wo�Ae.- -e 1r`sMe- V% xclnnP esw V"Vj%S L�Ak Ilam& <br /> v <br /> Inspection Form Included: Q <br /> Comments Included: •� ye (� %' 4v '1 <br /> Busine ep's Ignature Phone Number Inspe tor's Signature Phone Number <br /> __] <br /> INSTRUCTIONS ON BACK Correct: Incorrect: 44 <br /> EXAMPLE1112'1:3] 62os1 <br /> ■ White Copy:CalRecycle Yellow Copy:Operator Pink Copy:LEA ® ■ <br />