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Waste Tire SL. .ie & Inspection Re or#nspection Report Number <br /> CalRecycle State of California Y _ <br /> CalRecycle 181(Rev.10/10) Survey Form Page 1 11 - 1177881 <br /> Dept.of Resources Recycling and Recovery(CalRecycle) <br /> Part A- Survey BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- � ^ _ O � Inspection Type(Fill one) <br /> Site Suffix: l 9 Routine Q Re-inspection Q Referral Q Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier: - <br /> J�.,�,`�,^ C(}t,��� Q CHP Q CalRecycle Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name ""`�` <br /> Inspected By Inspector <br /> Na`veAnC4,A 7fK�k( _ Subs Sl�r;re� 3 _ C� 1ll' <br /> Physical Address CS �N U <br /> Inspection Date 1 / 0 C A gSLos «l4VV/ <br /> Time In Time Out <br /> Business Rep Title I O 10 AM 0U Q AM <br /> QPM ` *PM <br /> Operational Status Tire Type Business Role Storage Type <br /> Tire Count(Whole/PTE) <br /> 5 (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> 0 Active ® Passenger ® Generator ® Outdoor <br /> O Q Closed O Altered <br /> GPS Latitude Q Hauler Q Indoor <br /> O Q Inactive 41 Truck <br /> Longitude - Q Planned • OTR O End-Use ® Container <br /> Business Type(Fill all that apply) <br /> Q New Tire Dealer Q Auto Repair Q Trucking Fleet Q 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 O Shredder ® Other 1 ca"L' <br /> Part B - Inspection of Waste Tire Dealer, Generator, Hauler and End-Use Facility ENFORCEMENT STATUS 11 <br /> V A HAULING AND MANIFEST REQUIREMENTS <br /> Notice Of Violation Q Extension <br /> O O PRC§42951 -Waste Tire Hauler Registration and Transport of Tires <br /> Q O PRC§42953-Contracts with Registered Waste Tire Haulers. Compliance Deadline <br /> 0 O PRC§42956-Registration/Decal in Vehicle <br /> 0 O 14 CCR§18459-Responsible Entities Complying with Manifesting Requirements Date M / m / m <br /> Q 14 CCR§18459.1 -Tire Program ID Number from CalRecycle N <br /> O O 14 CCR§18459.2.1 -Submittal of Comprehensive Trip Logs within 90 days (Required for NOV or EXE <br /> O Q 14 CCR§18459.3-Retention of Comprehensive Trip Logs for 3 years <br /> O O 14 CCR§18460.2-Manifest System Requirements for Registered Waste Tire Haulers Q Referred/CalRecycle Enforcement <br /> O O 14 CCR§18461 -Manifest System Requirements for Waste Tire End-Use Facilities W <br /> O Q 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators ®In Compliance-No Violations o <br /> O Q Other:§ <br /> Comments ii W t1b�G� � I -Z' 1' 1, 0^ 1 r (�1- <br /> Inspection Form Included: Q <br /> Comments Included: ®- <br /> siness Rep's Signature Phone Number Insp or's Signature Phone Number <br /> INSTRUCTIONS ON BACK Correct: Incorrect: � �� E X A M 1 2 3 62081 <br /> White Copy:CalRecycle Yellow Copy:Operator Pink Copy: EA <br />