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Waste Tire Aley & Inspection Re O 0. 1spection Report Number <br /> State of California <br /> CalRecycle CalRecycle 181(Rev.10/10) 1176614Survey Form - Page 1 <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: (Q S ( 0 Routine 0 Re-inspection 0 Referral 0 Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier: Q , , N 0 CHP 0 CalRecycle 0 Complaint 0 Educational Visit 0 Other <br /> Business or Facility Name Inspected By Inspector <br /> Physic AdJress <br /> '�303 S. �Kec L - <br /> CA � Z�O <br /> � Inspection Date <br /> ` Time In / Time Out <br /> Business Rep Title O AM 0 AM <br /> I '� . d Q 0 P Q QPM <br /> 1t71>&,r C1 C_-,CL <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 /> 0 Active ® Passenger g ® Generator ® Outdoor <br /> 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 /> ® New Tire Dealer 0 Auto Repair 0 Trucking Fleet 0 Government 0 Retreader 0 Dismantler 0 Tire Derived Fuel <br /> 61 Used Tire Dealer 0 Auto Body 0 Car Dealer 0 Collection 0 Crumb Rubber <br /> 0 Service Station 0 Hauler 0 Agriculture 0 Shredder 0 Other <br /> Part B - Inspection of Waste Tire Dealer, Generator, Hauler and End-Use Facility FENFoRCEMENT STATUS j <br /> ----- --------- <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 /> 0 0 PRC§42956-Registration/Decal in Vehicle <br /> 0 0 14 CCR§18459-Responsible Entities Complying with Manifesting Requirements Date m / m / m <br /> 0 0 14 CCR§18459.1 -Tire Program ID Number from CalRecycle <br /> (Required for NOV or EXTj <br /> 0 0 14 CCR§18459.2.1 -Submittal of Comprehensive Trip Logs within 90 days N <br /> r <br /> 0 0 14 CCR§18459.3-Retention of Comprehensive Trip Logs for 3 years <br /> 0 0 14 CCR§18460.2-Manifest System Requirements for Registered Waste Tire Haulers 0 Referred/CalRecycle Enforcement <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 <br /> L4011 <br /> ompliance-No Violations o <br /> 1010 Other:§ __.... - -- <br /> - - z <br /> Comments L, <br /> Inspection Form Included: 0 <br /> Comments Included: - - �ectr's <br /> ��,r„ ��Pho�ne <br /> Z3Business Rep' ignature Phone Dumber Signature ber <br /> INSTRUCTIONS ON BACK Correct Incorrect: ] E I X I A M E 1 Z 3 62081 <br /> White Copy:CalRecycle Yellow Copy:Operator Pink Cop :LE <br />