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Inspection Report Number <br /> Waste Tire Sup vey & Inspection Report � <br /> CalRecycle State of California — <br /> CalRecycle 181(Rev.10/10) Survey Form - Page 1 1 1230446 <br /> Dept.of Resources Recycling and Recovery(CalRecycle) <br /> BLUE OR BLACK INK PEN <br /> Part A-Survey <br /> Business Profile Inspection Details <br /> TPID- Q __7Z _ O 1 Inspection Type(Fill one) <br /> Site Suffix: tO Routine Q Re-inspection Q Referral Q Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier. ��� 30CCV V'� COv Q CHP Q CalRecycle Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name Inspected By Inspector <br /> Physl A <br /> icadN,'ss r F b I M'A� \ <br /> 1 V <br /> 71 5 tE � c - <br /> Inspection Date <br /> J J Time In Time Out <br /> Business Rep Title 0 AM >7 O AM <br /> M I ® PM 0 PM <br /> Operational Status Tire Type Business Role Storage Type <br /> 1 <br /> Tire Count(Whole/PTE) - (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> C1 <br /> 0 Active Q Passenger 40 Generator f Outdoor9$ <br /> Q Closed Q Altered <br /> GPS Latitude Q Hauler 0 Indoor 41 <br /> O Q Inactive 0 Truck <br /> Longitude - Q Planned Q OTR Q End-Use Q Container <br /> Business Type(Fill all that apply) <br /> New Tire Dealer Q Auto Repair Q Trucking Fleet Q Government Q Retreader Q Dismantler Q Tire Derived Fuel <br /> 0 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 1 n tiC-\A �c <br /> Part B- Inspection of Waste Tire Dealer,Generator, Hauler and End-Use Facility ENFORCEMENT STATUS <br /> V A HAULING AND MANIFEST REQUIREMENTS <br /> 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 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 EXE N <br /> Q Q 14 CCR§18459.3-Retention of Comprehensive Trip Logs for 3 years a <br /> Q Q 14 CCR§18460.2-Manifest System Requirements for Registered Waste Tire Haulers Q Referred/CalRecycle Enforcement <br /> Q Q 14 CCR§18461 -Manifest System Requirements for Waste Tire End-Use Facilities w <br /> Q Q 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators <br /> •In Compliance-No Violations o <br /> Q Q Other:§ <br /> Comment 1 _ <br /> ����.�rx��;.�,� t.►.�raSk �i.� :v�So�c�"�c»n �.c�,r.P c»n �.`, �,c�.t� <br /> �� ��ib�ca�T�big G F �('e0.S d�' Cnv�cec�✓1.g <br /> Inspection Form Included: Q ` <br /> Comments Included: <br /> usiness ep's Signature Phone Number Inspe or's Signature Phone Number <br /> INSTRUCTIONS ON BACK I Correct:is Incorrect: R*Y]IEIXIAIMIPILIEI 1112 3 62081 <br /> ® White Copy:CalRecycle Yellow Copy:Operator Pink Copy:LEA ® 0 <br />