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r <br /> Waste Tire SL. rey & Inspection Report <br /> Ir,_,,ection Report Number <br /> CalRecycle State of cle 181(R I 1 - 1177967 <br /> CalRecycle 181(Rev.10H0) Survey Fora o 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- /_ 11-7 _ l Inspection Type(Fill one) <br /> Site Suffix: lQ le / Q Routine 0 Re-inspection 0 Referral 0 Observation <br /> Local LAI <br /> C(D ld�J3 If Referral,choose referral type(Fill one) <br /> Identifier: �Q(� J OCL <br /> 1 0 CHP 0 CalRecycle 0 Complaint 0 Educational Visit 0 Other <br /> Business or Facility Name Inspected By Inspector <br /> � 1 <br /> f� <br /> Physical Address <br /> 3o3 5_ <br /> Inspection Date <br /> Time In Time Out <br /> Business Rep Title O AM cO AM <br /> I I I . 1 5 ® PM J 0 0 PM <br /> �1 b►1 U m cc�¢Ut. ��UCe m (�,t��u n;�- <br /> Operational Status Tire Type Business Role Storage Type <br /> Tire Count(Whole/PTE) L (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> ' ' 1 0 Active 0 Passenger ® Generator ® Outdoor <br /> 0 Closed 0 Altered <br /> Ca P$ 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 /> ® 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 ENFORCEMENT STATUS <br /> V A HAULING AND MANIFEST REQUIREMENTS <br /> 0 0 PRC§42951 -Waste Tire Hauler Registration and Transport of Tires 0 Notice Of Violation Extension <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 m <br /> 0 0 14 CCR§18459.1 -Tire Program ID Number from CalRecycle N <br /> 0 0 14 CCR§18459.2.1 -Submittal of Comprehensive Trip Logs within 90 days (Required for NOV or EX7) 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 /> 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 /> in Compliance-No Violations o <br /> 0 1 0 1 Other:§ <br /> Comments <br /> Q_nAl <br /> bA"I <br /> " �S <br /> VI' _CSS (M z6 s C_.b()Cern . <br /> Inspection Form Included: 0 - n �O /cl ��5 <br /> Comments Included: 0 Ilr f��l <br /> Business Rep's Signature Phone Number �Inspfejc 's Signature hone Number <br /> INSTRUCTIONS ON BACK Correct* Incorrect: � � � EXAM E 1 2 3 62081 <br /> White Copy:CalRecycle Yellow Copy:Operator Pink Copy: ® r <br />