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Waste Tire Survey & Inspection Report Inspection Report Number <br /> State of California <br /> CalRecycle <br /> CalRecycle 181(Rev.10/10) Survey Form - Page 1 11 - 1210263 <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: i O 9 Q 57 -7 1 (f Routine Q Re-inspection Q Referral Q Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier: Q CHP Q CalRecycle Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name Inspected By Inspector <br /> Ler_)-, 0, & , is - t o t <br /> Physical Address 49wl4G Ui-4 <br /> s , G u 4- A-Lit, <br /> Inspection Date 6-, <br /> L CJS.e � /�� C(;S.��-C V <br /> Time In Time Out <br /> Business Rep Tittle �./ 12) AM AM <br /> �l�l. ��1.�1C✓W.�.�r` `C� �ICG�,� 1 L 1 (f) o PM l l 5 o PM <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) all that apply) <br /> IS Active ® Passenger ® Generator 41FOutdoor <br /> O Q Closed Q Altered <br /> GPS Latitude Q Hauler Q Indoor <br /> O Q Inactive 0 Truck <br /> Longitude - Q Planned Q OTR Q End-Use (9 Container <br /> Business Type(Fill all that apply) <br /> Q New Tire Dealer Q Auto Repair Q Trucking Fleet • 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 Q 14 CCR§18459-Responsible Entities Complying with Manifesting Requirements Date m / Ffl m <br /> Q Q 14 CCR§18459.1 -Tire Program ID Number from CalRecycle W <br /> Q Q 14 CCR§18459.2.1 -Submittal of Comprehensive Trip Logs within 90 days (Required for NOV or E)CT) <br /> Q Q 14 CCR§18459.3-Retention of Comprehensive Trip Logs for 3 years o <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 In Compliance- No Violations o <br /> Q Q Other:§ <br /> Comments <br /> �--ovN 1'Y6 i <br /> Inspection Form Included: <br /> Comments Included: <br /> Business Rep's Signature Phone Numberp or' ig ture Phone Number <br /> 1.4 62081 <br /> INSTRUCTIONS ON BACK Correct: Incorrect: E X A L 1 2 3 <br /> White Copy:CalRecycle Yellow Copy:Operator Pink Co y: <br />