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Waste Tire Avey & Ins ection Re or , Inspection Report Number <br /> CalRecycle State of California <br /> CalRecycle 181(Rev.10/10) 1255850(CalRecycle) Survey <br /> I1 - <br /> Dept.of Resources Recycling and Recovery(CalRecycle) Survey Form - Page 1 <br /> Part A- Survey BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- Inspection� � � n � _ © � Inspection Type(Fill one) <br /> Site Suffix: 1 "4 `Routine Q Re-inspection Q Referral Q Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier: �jp`yTo a Q CHP Q CalRecycle Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name Inspected By Inspector <br /> •\� <<0.-,S ��a`�:o `n <br /> Physical Address - 1 ' MA_ _TN <br /> Inspection Date <br /> Time In Time Out <br /> Business Rep Title(-e-,- AM AM r 0 AM <br /> 5'.I�t\Z ` / \) 1 l� 0 PM ` 0 PM <br /> ck0.v I� (��h-la P cta`i5 S �((,, <br /> Operational Status Tire Type Business Role Storage Type <br /> 9j( (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> Tire Count(Whole/PTE) lV"� <br /> Q Active Q Passenger Q Generator Q Outdoor <br /> 0 * Closed Q Altered. A/r l�GPS Latitude ,�J Q HQ Indoor <br /> 0 Q Inactive Q Truc <br /> Longitude - Q Planned Q OTR Q End-Use Q Container <br /> Business Type(Fill all that apply) <br /> Q New Tire Dealer Q Auto Repair 0 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 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 EXT) N <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 /> I^ 1 <br /> Comments ` T � �� � r, <br /> �.P A4� `� ^'��CSv� v�2 C3-t-, � Q <br /> Ll 9 <br /> -a1 w. <br /> Inspection Form Included: Q <br /> Comments Included. <br /> siness Rep's Signature Phone Number Inspe tor's Signature Phone Number <br /> INSTRUCTIONS ON BACK Correct:1* Incorrect: E�XJA�MJPJLJEJ 11 2 3 62081 <br /> White Copy:CalRecycle Yellow Copy:Operator Pink Copy:LEA <br />