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Waste Tire SLftey & Inspection Reporonspection Report Number <br /> CalRec cle State of California <br /> Y CalRecycle 181(Rev.10/10) Survey Form - Page 1 I1 - 1177545 <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 7 O A - O 1 Inspection Type(Fill one) <br /> Site Suffix: 0 Routine Q Re-inspection Q Referral Q Observation <br /> Local �, If Referral,choose referral type(Fill one) <br /> Identifier: e,aQ1U� Cer Q CHP Q CalRecycle Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name � Inspected By Inspector <br /> Cev`kj_a,\ V aX\eY U l �'1 a �'vK <br /> Physical Address <br /> X333 �Z& <br /> Inspection Date -3 S / 1 3 <br /> U,&'.' CA CkS2`1l <br /> Time In Time Out <br /> Business Rep Title Z O AM u O AM <br /> p k 3 S 0 PM � ` D � PM <br /> �' t�� ` Operational Status Tire Type Business Role Storage Type <br /> Tire Count(VNhol (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> eE� O <br /> 0 Active 0 Passenger 0 Generator Q Outdoor <br /> O Q Closed Q Altered <br /> GPS Latitude Q Hauler Q Indoor <br /> O Q Inactive 4&Truck <br /> Longitude - Q Planned OTR Q End-Use 41 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 Q Shredder a Other 1 rav,S' tr S'C"%OV) <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 /> Q Q PRC§42956-Registration/Decal in Vehicle <br /> Q Q 14 CCR§18459-Responsible Entities Complying with Manifesting Requirements Date m / m / m <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 EXE <br /> Q Q 14 CCR§18459.3-Retention of Comprehensive Trip Logs for 3 years <br /> 0 <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 �OV�i V1 61�in U-3 '�i t'� i S f? -r—CXt b h &el,V\Q O✓) AA'\� S <br /> AoAct- 0.v k-\v.2 t o w we s <br /> nce�'� <br /> Inspection Form Included: Q/tom'7� 2nq-968-328 �J <br /> Comments Included: U-4: - - - T �6o'G1�` - 1 '1 U O J_ <br /> Business Rep's Signature Phone Number Inspe or's Signature Phone Number <br /> INSTRUCTIONS ON BACK I Correct: Incorrect: E X A M P L E 1 62081 2 3 <br /> White Copy:CalRecycle Yellow Copy:Operator Pink Copy:LEA <br />