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Waste Tire SU*e & Inspection Re ortelnspection Report Number <br /> CalRecycle p p <br /> State of CaliforniaCaliforniaY CalRecycle 181(Rev.10/10) Survey Form - Page 1 1 - 1177559 <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 /> Site Suffix: < Li `� t J ® 4&Routine Q Re-inspection Q Referral Q Observation <br /> Local Savx � If Referral,choose referral type(Fill one) <br /> Ll <br /> Identifier: "lt h <br /> Q CHP Q CalRecycle Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name Inspected By Inspector <br /> ��. vet a�U / <br /> Physical`P(ddress 3 <br /> {{ Inspection Date / f <br /> cA ( 3s6 Time In Time Out <br /> Business Rep Title O AM O AM <br /> d vxl 110P I ';L ' ..S '�3 0 PM O ® 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 /> Q Active 0 Passenger ® Generator Q Outdoor <br /> O ® Closed Q Altered <br /> GPS Latitude Q Hauler Q Indoor <br /> O Q Inactive (aTruck <br /> Longitude — Q Planned Q 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 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 ® OtherUYIU ✓ <br /> Part B - Inspection of Waste Tire Dealer, Generator, Hauler and End-Use Facility ENFORCEMENT STATUS <br /> V I A I 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 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 <br /> M / 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 or EXT) 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 /> Lu <br /> Lu <br /> Q Q 14 CCR§18461 -Manifest System Requirements for Waste Tire End-Use Facilities - <br /> CR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators <br /> Q Q 14 Cem <br /> ®In Compliance-No Violations o <br /> Q Q Other: <br /> Comments <br /> s <br /> Inspection Form Included: Q <br /> Comments Included. <br /> Business Rep's Signature Phone Number sectorSi nature Phone Number <br /> INSTRUCTIONS ON BACK I Correct: Incorrect: W 62081 <br /> q E X A L E 1 2 3 <br /> White Copy:CalRecycle Yellow Copy:Operator Pink Copy:LFA <br />