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Waste Tire Slkey & Inspection Repor ,, Inspection Report Number <br /> State of California <br /> CalRecycle I 1 1245211 <br /> CalRecycle 181(Rev10/10) <br /> . <br /> (Cal Survey Form - Page 1 <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 � _ � � Inspection Type(Fill one) <br /> Site Suffix: ®Routine Q Re-inspection Q Referral Q Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier: ~\/`Y-� ut r � Q CHP Q CalRecycle Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name -��'�1 Inspected By Inspector <br /> Physical Address --,7 e--i - / o <br /> 120 F K'L.kQL Vu w- cb-C'U" <br /> Inspection Date <br /> Time In JJ Time Out <br /> lJ <br /> Business Rep Title r� 0 AM -7 �j O AM <br /> 1 -7-- : 0 & GPM � L . � \1 WPM <br /> 4S g Li •S r��E <br /> pera onal 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 OP Generator Outdoor <br /> Q Closed Q Altered �y <br /> GPS Latitude Q Hauler ® Indoor 7 <br /> O Q Inactive ®Truck <br /> Longitude - Q Planned ® OTR Q End-Use Q 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 ® Other , - <br /> Part B - Inspection of Waste Tire Dealer, Generator, Hauler and End-Use Facility ENFORCEMENT ATUS <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 O 14 CCR§18459-Responsible Entities Complying with Manifesting Requirements Date m / m / m <br /> Q O 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 N <br /> a <br /> Q Q 14 CCR§18459.3-Retention of Comprehensive Trip Logs for 3 years o <br /> Q O 14 CCR§18460.2-Manifest System Requirements for Registered Waste Tire Haulers Q Referred/CalRecycle Enforcement <br /> Q O 14 CCR§18461 -Manifest System Requirements for Waste Tire End-Use Facilities W <br /> Q O 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators ®In Compliance-No Violations o <br /> Q Q Other:§ <br /> Commentsjbcwb �,y n (., (� �L,, <br /> YL Q i��r // C-'1 UZ�Y�. �i' OA,jQ(.Ltr cL G�n `I�CJ� c6.-tx c - <br /> ^ J <br /> Inspection Form Included: Q _ <br /> Comments Included: N/A �� / 403 <br /> 99wss 1p's Signature Phone Number Inspector' Ignature Phone Number <br /> INSTRUCTIONS ON BACK Correct: Incorrect: JEJXJAJM L 1 2 3 62081 <br /> White Copy:CalRecycle Yellow Copy:Operator Pink Cop L <br />