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Waste Tire Suave & Inspection Repo Inspection Report Number <br /> CalRecycle State of California Y p — <br /> CalRecycle 181(Rev.10/10) I1 1245342 <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- / /� (% �( / /j. _ U Inspection Type(Fill one) <br /> Site Suffix: ( vl D !> (y `r 4$ Routine Q Re-inspection Q Referral Q Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier: �l(� y� C(�L1�L Q CHP Q CalRecycle Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name Inspected By Inspector <br /> Physical Address .� 1 f <br /> 1 �� � - ►-fw� 12c� <br /> Inspection Date / a J / S <br /> Time In Time Out <br /> Business Rep TittleJ 0 O AM 1^ 0 AM <br /> ffu�A-vo(h5 Cll ,, fQ �, `''( ® M 3 V ® PMr�tl�tr�� J Y <br /> 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 /> 0 ® Active Q Passenger & Generator Q Outdoor <br /> 0 Q Closed Q Altered p <br /> GPS <br /> Latitude Q Hauler Q Indoor <br /> � <br /> 0 Q Inactive Q Truck <br /> Longitude - Q Planned ® OTR Q End-Use Q Container <br /> Business Type(Fill all that apply) Q� <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 0 Other \kjtY-Ne <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 /> 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 EXT) N <br /> Q l0 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 tt t � <br /> ? Zts� <br /> ZO C•��(J <br /> Inspection Form Includ: Q <br /> Comments Inclu GGA <br /> Bu ness Re 's Sighkture Phone Number Inspector's Signature Phone Number <br /> EXAMPLE 62081 <br /> INSTRUCTIONS ON BACK Corr Incorrect: <br /> ■ White Copy:CalRecycle Yellow Copy:Operator Pink Copy:LEA ® ■ <br />