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Waste Tire Survey & Inspection Report Inspection Report Number <br /> cle State of California <br /> CalRecycle Y CalRecycle 181(Rev.10/10) 11 Form - Page 1 11 - 1210589 <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: /1 L4 -1 Lq t) 1 O Routine Q Re-inspection Q Referral Q Observation <br /> LocalV (( � If Referral,choose referral type(Fill one) <br /> Identifier: �(,t VL �Gri _ CO vrvl Q CHP Q CalRecycle Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name l/ Inspected By Inspector <br /> ir� wti l v''14,�dw <br /> Physical <br /> ical Address � I - <br /> Inspection Date <br /> s�Oc�l��z GIS <br /> Time In Time Out <br /> Business Rep Title ` AM / ®AM <br /> p ` 3 O PM 1 Q PM <br /> f'�li��'11a1(;�Li_C.i (1.t�2Lt�1/` IMCt <br /> - Operational Status Tire Type Business Role Storage Type <br /> Tire Count (Whole/PTE) D (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> ® Active ® Passenger 10 Generator ® Outdoor <br /> O Q Closed Q Altered <br /> GP� Latitude Q Hauler Q Indoor <br /> O Q Inactive Q 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 /> ® 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 I 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 Q 14 CCR§18459-Responsible Entities Complying with Manifesting Requirements Date M / F11 / 7 <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 /> 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 /> uj <br /> Q Q 14 CCR§18461 -Manifest System Requirements for Waste Tire End-Use Facilities _ _ u, <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 /> Comments <br /> Inspection FormIncluded: Q <br /> Comments Included: ® 0 r 7 <br /> iusinessgRe4jignature Phone Number n ect 's S' nature Phone Number <br /> INSTRUCTIONS ON BACK Correct:0 Incorrect: EXAM LE 1 2 3 62081 <br /> 7X7�� �J <br /> 0 White Copy:CalRecycle Yellow Copy:Operator Pink Copy:LEA ® ■ <br />