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Waste Tire Ekey & Inspection Repor ,, Inspection Report Number <br /> CalRecycle State of California 11 - 1230284 <br /> CalRecycle 181(Rev.10110) 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- Inspection Type(Fill one) <br /> Q <br /> Site Suffix: 1 � 00 O Routine Q Re-inspection Q Referral Q Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier: Sail 0` n `(j1,{c1�1/� Q CHP Q CalRecycle Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name ✓l_ I 1 Inspected By Inspector <br /> 3 <br /> CA- ' - Il <br /> Physical Adclss(Y+ 1 � b � <br /> 1-IN S - �A tt rv\ Lo . <br /> Inspection Date <br /> L act I �A at s�.0 Z <br /> Time In Time Out <br /> Business Rep Title / I 6 � ' O V 0 AM <br /> AM <br /> Y � PM <br /> Q4 FCt'T 0 1 0� � 1. 0 PM <br /> Operational Status Tire Type Business Role Storage Type <br /> 1 y, <br /> Tire Count(Whole/PTE) <br /> (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> ` Xv <br /> ® Active 0 Passenger • Generator • Outdoor <br /> Q Closed Q Altered <br /> GPS Latitude Q Hauler ® Indoor <br /> O Q Inactive 46 Truck <br /> Longitude — Q Planned Q OTR ® End-Use Q Container <br /> Business Type(Fill all that apply) <br /> Q New Tire Dealer Q Auto Repair Q Trucking Fleet • 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 / 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 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 O In Compliance-No Violations o <br /> Q Q Other:§ <br /> Comments <br /> bl�i����,n(TI tet/► ` -- - <br /> N�, j ol4l)n5 n1;!-cfS 4 con cora _ <br /> Inspection Form Included: Q _ <br /> a T7 <br /> Comments Included: 11 <br /> Rep <br /> siness 's Signature hone Number Insp tor's Sig ature Phone Number <br /> 62081 <br /> INSTRUCTIONS ON BACK Correct: Incorrect: E X AE 1 2 3 <br /> ■ White Copy:CalRecycle Yellow Copy:Operator Pink Co :L A <br />