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Waste Tire SU,vey & Inspection Report Inspection Report Number ■ <br /> CalRecycle State of California <br /> CalRecycle 181(Rev.10/10) Survey Form - Page 1 I1 - 1210343 <br /> Dept.of Resources Recycling and Recovery(CalRecycle) BLUE OR BLACK INK PEN <br /> Part A-Survey_ <br /> Business Profile Inspection Details <br /> TPID- 1 _ O ' Inspection Type(Fill one) <br /> Site Suffix: 0 Routine Q Re-inspection Q Referral Q Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier: h V b 6-k C\ Co 0 / Q CHP Q CalRecycle Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name / ` r Inspected By Inspector <br /> D f.A O S\-ock\-,:,V\. / ���rC� �o m C1 1 A TT <br /> Physical Address ` <br /> p' Inspection Date 6 / , Z <br /> Time In � 1 <br /> 1 S Z 3` Time Out <br /> Business Rep Title 1 O AM O AM <br /> " t -Z1 d * PM � � � 0 PM <br /> �tt�Tertb <br /> - - Operational Status Tire Type Business Role Storage Type <br /> Tire Count(Whole/PTE) 1 - (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> 37 0 Active Q Passenger 0 Generator Q Outdoor <br /> GPS Latitude 0 Closed Q Altered <br /> Q Hauler a Indoor <br /> O Q Inactive Q Truck <br /> Longitude — Q Planned 0 OTR Q End-Use 0 Container <br /> Business Type(Fill all that apply) oc kV: <br /> Q New Tire Dealer Q Auto Repair Q Trucking Fleet 4P 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 Q 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 /> 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 O 14 CCR§18459-Responsible Entities Complying with Manifesting Requirements Date <br /> Q O 14 CCR§18459.1 -Tire Program ID Number from CalRecycle <br /> Q O 14 CCR§18459.2.1 -Submittal of Comprehensive Trip Logs within 90 days (Required for NOV or EXT) n <br /> Q Q 14 CCR§18459.3-Retention of Comprehensive Trip Logs for 3 years <br /> Q Q 14 CCR§18460.2-Manifest System Requirements for Registered Waste Tire Haulers Q Referred/CalRecycle Enforcement <br /> w <br /> Q O 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 <br /> Inspection Form Included: Q <br /> Comments Included: tJ <br /> Business Rep's Signature Phone Number Inspe or's Signature Phone Number <br /> INSTRUCTIONS ON BACK Correct: Incorrect: IEIXIAIMIPILIEI 11 2 3 62081 <br /> ■ White Copy:CalRecycle Yellow Copy:Operator Pink Copy:LEA <br />