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Waste Tire Survey & Inspection Report Inspection Report Number ■ <br /> CalRecycle State of California <br /> CalRecycle 181(Rev.10/10) 11 - 1196302 <br /> Dept.of Resources Recycling and Recovery(CalRecycle) BLUE <br /> Form - Page 1 BLUE OR BLACK INK PEN <br /> Part A-Survey i - <br /> Business Profile Inspection Details <br /> TPID- <br /> Inspection Type(Fill one) <br /> gSite Suffix: 12 Routine 0 Re-inspection 0 Referral 0 Observation <br /> Local ` if Referral,choose referral type(Fill one) <br /> Identifier: V1, " tCtLAN-\_ Gam' 0 CHP 0 CalRecycle 0 Complaint 0 Educational Visit 0 Other <br /> Business or Facility Name Inspected By Inspector <br /> Physical Address <br /> Inspection Date <br /> ISA-D&L11,� c-A 5,�06 Time In Time Out <br /> Business Rep Title 0 AM 0 AM <br /> 0 PM 0 PM <br /> operational Status Tire Type Business Role Storage Type <br /> (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> Tire Count('=PTE) <br /> Count(Whole I Active 0 Passenger M Generator I* Outdoor <br /> 0 0 Closed 0 Altered <br /> GPS <br /> Latitude 0 0 Inactive Truck 0 Hauler 0 indoor <br /> Longitude 0 Planned OTR 0 End-Use 0 container <br /> Business Type(Fill all that apply) <br /> 0 New Tire Dealer Q Auto Repair 0 Trucking Fleet 0 Government 0 Retreader 0 Dismantler 0 Tire Derived Fuel <br /> 0 Used Tire Dealer 0 Auto Body 0 Car Dealer 0 Collection 0 Crumb Rubber <br /> 0 Service Station 0 Hauler 0 Agriculture 0 Shredder Other n�i <br /> Part B- Inspection of Waste Tire Dealer, Generator, Hauler and End-Use Facility ENFORCEMENT STATUS <br /> V A HAULING AND MANIFEST REQUIREMENTS 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 N <br /> 0 0 14 CCR§18459.1 -Tire Program ID Number from CalRecycle <br /> (Required for NOV or EXT) N0 0 14 CCR§18459.2.1 -Submittal of Comprehensive Trip Logs within 90 days <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 /> 2 <br /> Lu <br /> 0 0 14 CCR§18461 -Manifest System Requirements for Waste Tire End-Use Facilities <br /> 0 0 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators in compliance-No Violations <br /> 0 0 <br /> Other:§ <br /> 11 1 <br /> Comments <br /> Inspection Form Included: 0 '18 6k4 74Qr- <br /> Comments Included: Busines; ep's Signature Phone Number In p t r' Sig ture Phone Num ber <br /> EXAM L 1 2 3 62081 <br /> INSTRUCTIONS ON BACK Correct:* I orrect: XA rW— <br /> ■ White Copy:CalRecycle Yellow Copy:Operator Pink Co y:L © ■ <br />