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Waste Tire SWey & Inspection Repor° Inspection Report Number <br /> cle State of California <br /> Cal Rec <br /> Y CalRecycle 181(Rev.10/10) Survey Form - Page 1 11 -1176599 <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: :Z LA 1 4 3 ® Routine 0 Re-inspection 0 Referral 0 Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier: t`_- 0 CHP 0 CalRecycle 0 Complaint 0 Educational Visit 0 Other <br /> Business or Facility Name Inspected By Inspector <br /> Physical 0 <br /> Inspection Date / .Z <br /> '` _tcw, Gh� �'s z1 <br /> Time In Time Out <br /> Business Rep Title O AM O AM <br /> 0 '? • C) Q ® PM o � © ® PM <br /> 5 .hvrr�' Operational Status Tire Type Business Role Storage Type <br /> Tire Count (Whole/PTE) r d (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> ' ® Active 0 Passenger ® Generator ® Outdoor <br /> O 0 Closed 0 Altered <br /> GPS Latitude 0 Hauler 0 Indoor <br /> O 0 Inactive 0 Truck <br /> Longitude - 0 Planned 0 OTR 0 End-Use 0 Container <br /> Business Type(Fill all that apply) I( <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 ® Other �l yr t i r s( S�-�z S <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 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 <br /> Q 0 14 CCR§18459.1 -Tire Program ID Number from CalRecycle <br /> Q 0 14 CCR§18459.2.1 -Submittal of Comprehensive Trip Logs within 90 days (Required for NOV or EXE <br /> 0 0 14 CCR§18459.3-Retention of Comprehensive Trip Logs for 3 years o <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 to <br /> 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators <br /> In Compliance No Violations o <br /> 0 <br /> Other:§ �_-. __..__..._..... <br /> _ <br /> Comments �1(u\A(I'jAA <br /> C�i7f.&.. [7fMc�lN <br /> Inspection Form Included: 0 <br /> 2oq-�16Z i��g Czo9� 6z3 <br /> Comments Included: ® - <br /> Business epaigurePhone NumberxlGiO $ spector's Signature Phone Number <br /> INSTRUCTIONS ON BACK Correct- Incorrect: E X A M P 2 3 szosi <br /> White Copy:CalRecycle Yellow Copy:Operator Pink Copy:Lor <br />