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0 Waste Tire Su, vey & lnspecUan Report Inspection Report Number <br /> CalRecycle State of California <br /> Y CalRecycle 181(Rev.10/10) 5� ®rr� - Page I1 1242218 <br /> Dept of Resources Recycling and Recovery(CalRecycle) <br /> PartA-Survey BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- Inspection� � C � _ � ( Inspection Type(Fill one) <br /> 1 <br /> Site Suffix: l C- <br /> ® Routine Q Re-inspection Q Referral Q Observation <br /> Local CV,,-K, If Referral,choose referral type(Fill one) <br /> Identifier: �-,G Vt Joctc ' Q CHP Q CalRecycle Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name 1 Inspected By Inspector <br /> A <br /> Physical Address S 1 �4 /imtg ui-- -{ <br /> aln c -- <br /> Inspection Date —7 <br /> Time In Time Out <br /> Business Rep Title O AM O AM <br /> ) � ®PM ' O G ® PM <br /> A` Operational Status Tire Type Business Role Storage Type <br /> Tire Count(Whole/PTE) (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> ' ® Active ® Passenger 0 Generator Q Outdoor <br /> Q Closed Q Altered <br /> ��� Latitude Q Hauler ®Indoor <br /> O Q Inactive Q Truck <br /> Longitude - Q Planned Q OTR Q End-Use Q Container <br /> Business Type(Fill all that apply) <br /> I® New Tire healer 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 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 <br /> PRC§42951 -Waste Tire Hauler Registration and Transport of Tires <br /> Q Q PRC§42953-Contracts with Registered Waste Tire Haulers. Compliance Deadline <br /> PRC§42956-Registration/Decal in Vehicle <br /> Q Q 14 CCR§18459-Responsible Entities Complying with Manifesting Requirements Date <br /> Q Q 14 CCR§18459.1 -Tire Program ID Number from CalRecycle <br /> Q Q 14 CCR§18459.2.1 -Submittal of Comprehensive Trip Logs within 90 days (Required for NOV or EX7) C2 <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 /> See- ��tW46 ka�e_' <br /> Inspection Form Included: Q <br /> Comments Included: 0 a <br /> Business ep's gnature Phone Number I pct gnature Phone Number <br /> 62081 <br /> INSTRUCTIONS ON BACK I Correct: Incorrect: E X A P L E 11213 <br /> ■ White Copy:CalRecycle Yellow Copy:Operator Pink Cp :L <br />