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Oa Waste Tire Arvey & Inspection Repo► ., Inspection Report Number <br /> State of California <br /> CalRecycle — <br /> CalRecycle 181(Rev.10/10) Survey Form - Page 1 I1 1245220 <br /> Dept.of Resources Recycling and Recovery(CalRecycle) <br /> Part A-_Survey_ BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- L ! ) Inspection Type(Fill one) <br /> Site Suffix: I S V 4 G f 0 Routine 0 Re-inspection 0 Referral 0 Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier: yry Ui 0 CHP 0 CalRecycle 0 Complaint 0 Educational Visit 0 Other <br /> Business or Facility Name Inspected By Inspector <br /> k� cu-k" <br /> Physical Address <br /> Inspection Date � � C) <br /> / Time In e� Time Out <br /> Business Rep Title � s0 AM 2 � � 0 AM <br /> V I�74� `. A PM is PM <br /> Operational Status Tire Type Business Role Storage Type <br /> Tire Count(Whole/PTE) I 3 (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> l ® Active 0 Passenger ® Generator 0 Outdoor <br /> 0 0 Closed 0 Altered <br /> GPS Latitude 0 Hauler 0 Indoor <br /> 0 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 0 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 ® Other 4+S Q✓1,z U-4, <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 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 /> M / m / m <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 EXE n <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 /> f <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 1 0 1 Other: <br /> Comments U § <br /> � ' ��� <br /> 2-o i,c rvx SL-► lam)at.1. —H _ <br /> • <br /> r <br /> lam' V 10Lax:-"cr_� 0y- <br /> Inspection Form Included: 0 <br /> Comments Included: <br /> Business Pep's Signature Phone Number Ins ector's Signa Phone Number <br /> INSTRUCTIONS ON BACK Correct: Incorrect: _ * V:] <br /> EXAM P L E 11 2 3 62081 <br /> White Copy:CalRecycle Yellow Copy:Operator Pink Copy&'� <br />