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Waste Tire Survey & Inspection Repon Inspection Report Number ■ <br /> CalRecycle State of California — <br /> Y CalRecycle 181(Rev.10/10) purvey Form - Page 1 I1 1242526 <br /> Dept.of Resources Recycling and Recovery(CalRecycle) <br /> Part A-Survey BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- q r1 _ /►r Inspection Type(Fill one) <br /> Site Suffix: I CT V ® Routine Q Re-inspection Q Referral Q Observation <br /> Local J - �� - If Referral,choose referral type(Fill one) <br /> Identifier: G\0 CA- LA',rl Q CHP Q CalRecycle Q Complaint <br /> Q Educational Visit <br /> Other <br /> Business or Facility Name Inspected By Inspector <br /> / <br /> Physical Address CS�o�Tb <br /> Inspection Date <br /> S50 C1�0 r� C A <br /> Time In Time Out <br /> Business Rep Title 2 00 AM <br /> 0 AM <br /> 1� 5 O 0 PM <br /> II ,, (0 PM <br /> �15�(�� OtN'� <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 /> ® Active 0 Passenger ® Generator Q Outdoor <br /> O Q Closed Q Altered <br /> ��� Latitude Q Hauler 4% Indoor <br /> O Q Inactive 0 Truck <br /> Longitude - Q Planned O 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 0 Other LAS( K_ <br /> Part B- Inspection of Waste Tire Dealer, Generator, Hauler and End-Use Facility ENFORCEMENT STATUS <br /> V A I 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 /> QQ 14 CCR§18459-Responsible Entities Complying with Manifesting Requirements Date m / <br /> FTI / 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 EXn N <br /> Q Q 14 CCR§18459.3-Retention of Comprehensive Trip Logs for 3 years <br /> Q Q 14 CCR§18460.2-Manifest System Requirements for Registered Waste Tire Haulers Q Referred/CalRecycle Enforcement <br /> f <br /> W <br /> Q Q 14 CCR§18461 -Manifest System Requirements for Waste Tire End-Use Facilities <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 D LA-4)-, `A�� ` P t 11 14 <br /> N <br /> 9-1) <br /> r �UCr�1(n l� In 5 01 <br /> c,(Al o� (Dj-1 r ern. <br /> Inspection Form Included: <br /> Comments Included: <br /> Business Rep's Signature Phone Number Ins tor's Signature Phone Number <br /> INSTRUCTIONS ON BACK Correct: Incorrect: X Qf EXAM L 1 2 3 62081 <br /> ■ White Copy:CalRecycle Yellow Copy:Operator Pink Copy.L ® ■ <br />