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Waste Tire S vey & Inspection Repor' <br /> Inspection Report Number <br /> CalRecycle State of California <br /> CalRecycle 181(Rev.10/10) Survey Form - Page 1 11 - 1177703 <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: t �j ® Routine 0 Re-inspection 0 Referral 0 Observation <br /> LocalC If Referral,choose referral type(Fill one) <br /> Identifier: 'S"Lv" 0 CHP 0 CalRecycle 0 Complaint 0 Educational Visit 0 Other <br /> Business or Facility Name Inspected By Inspector <br /> 1:�A_nX_ 1 4v;% 6.r'L <br /> Physical Address j ( �i �l/� /► <br /> $�O Cu vv rc� C i UVJ v cJ <br /> ` Inspection Date <br /> Time In Time Out <br /> Business Rep `T' e ` ® AM ,A 'O AM <br /> C7t>t! ti YSCi f Q L j 0 PM l r T 0 PM <br /> R - <br /> Operational Status Tire Type Business Role Storage Type <br /> Tire Count (Whole/PTE) 1-55 (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> 0 Active 4 Passenger 49 Generator ® Outdoor <br /> O 0 Closed 0 Altered <br /> GPS Latitude 0 Hauler Indoor <br /> 0 0 Inactive 0 Truck <br /> Longitude - 0 Planned 4f OTR 0 End-Use 0 Container <br /> Business Type(Fill all that apply) <br /> 0 New Tire Dealer 0 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 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 Notice Of Violation Extension <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 II <br /> 0 0 14 CCR§18459.1 -Tire Program ID Number from CalRecycle l <br /> 0 0 14 CCR§18459.2.1 -Submittal of Comprehensive Trip Logs within 90 days (Required for NOV or EXT) N <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 /> f <br /> 0 0 14 CCR§18461 -Manifest System Requirements for Waste Tire End-Use Facilities _ m <br /> 0 0 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators In Compliance-No Violations o <br /> 0 0 Other:§ <br /> Comments <br /> u <br /> Inspection Form Included: 0 ( -77.5--25 <br /> � <br /> Comments Included: J4_ <br /> Business Rep's Signature Phone Number n cto i ature Phone Number <br /> �-,( 62081 <br /> INSTRUCTIONS ON BACK Correct:0 Incorrect: X � NJ E X AA E 2 3 <br /> ® White Cope Recycle Yellow Copy:Operator Pi Cor 4 ® ■ <br />