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w.�s.m..-"..i�l • �.-._��-=_.:ST\. - �-�+.•.'-.Y w Ctitw\�ti�a.�+:a]�D'!'!s_-\.�:�..fS:nv.Ye:�b:.+-:cial.S.i•3'iLi:3 a s�:a1s1�:2ea'+�ti',3Rt_vlk}_,-a;:a.ctivatti��s. ia�cwt•s-a-,..•aac:.x.;a <br /> 03' `waste Tire Surusy & Inspection Report Inspection Report Number . <br /> State of California <br /> CalRecycle CalRecycle 181(Rev.10/10) 1244948cry Form _ page I 1 - <br /> Dept of Resources Recycling and Recovery(CalRecycle) <br /> Part A-Survey BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- 1 r7 q r, a C l 1 , - ,D Inspection Type(Fill one) <br /> Site Suffix: 6 I 8 "� a Routine 0 Re-inspection 0 Referral 0 Observation <br /> Local CIf Referral,choose referral type(Fill one) <br /> Identifier: An v U-� )l C) 0 CHP 0 CalRecycle 0 Complaint 0 Educational Visit 0 Other <br /> Business or F Cllity Name Inspected By Inspector <br /> Physical Address 31 - lon CA 9WO <br /> Inspection Date <br /> Time In Time Out <br /> Business{hep Title0 ® AM ��--•�� ® AM <br /> _ 0 �/ 0 PM V 3 O 0 PM <br /> Operational Status Tine 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 /> J `J ® Active 0 Passenger 0 Generator 0 Outdoor <br /> O 0 Closed 0 Altered <br /> GPS Latitude 0 Hauler ® Indoor <br /> O 0 inactive 0 Truck <br /> Longitude - 0 Planned 0 OTR 0 End-Use 0 Container <br /> Business Type(Fill all that apply) <br /> 0 New Tire Dealer 0 Auto Repair ® Trucking Fleet 0 Government 0 Retreader 0 Dismantler 0 Tire Derived Fuel <br /> 0 Used Tire Dealer 0 Auto Body 0 Car Dealer 0 Collection 0 Crumb Rubber <br /> 0 Service Station 0 Hauler 0 Agriculture 0 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 /> 0 Notice Of Violation 0 Extension <br /> 0 0 <br /> PRC§42951 -Waste Tire Hauler Registration and Transport of Tires <br /> 0 0 PRC§42953-Contracts with Registered Waste Tire Haulers. Compliance Deadline <br /> PRC§42956-Registration/Decal in Vehicle <br /> 0 0 14 CCR§18459-Responsible Entities Complying with Manifesting Requirements Date <br /> 0 0 14 CCR§18459.1 -Tire Program ID Number from CalRecycle <br /> 0 0 14 CCR§18459.2.1 -Submittal of Comprehensive Trip Logs within 90 days (Required for NOV or EXT) N <br /> r <br /> 0 0 14 CCR§18459.3-Retention of Comprehensive Trip Logs for 3 years o <br /> 0 0 14 CCR§18460.2-Manifest System Requirements for Registered Waste Tire Haulers 0 Referred/CalRecycle Enforcement <br /> 0 0 14 CCR§18461 -Manifest System Requirements for Waste Tire End-Use Facilities W <br /> 0 0 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators ®in Compliance-No Violations o <br /> 0 0 Other:§ <br /> Comments f ; f)C <br /> oj UcwAs 64 canr�fr,. <br /> Inspection Form Included: <br /> Comments Included: <br /> Business Rep's Signature Phone Number Insp or's Signature Phone Number <br /> __ 7INSTRUCTIONSON BACK Correct:Ill, Incorrect: _ � EXAM P L 1 2 3 62081 <br /> 0 White Copy:CalRecycle Yellow Copy:Operator Pink Cop . ® ■ <br />