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Waste Tire Survey & Inspection Report Inspection Report Number <br /> CalRec cle State of California <br /> Y CalRecycle 181(Rev.10/10) 11 Form - Page 1 1 -1176737 <br /> Recycle) <br /> Dept.of Resources Recycling and Recovery(CalRecycle) Survey <br /> BLUE OR BLACK INK PEN <br /> Part A- Survey <br /> Business Profile Inspection Details <br /> TPID- I r7 CD <br /> q C� Q Inspection Type(Fill one) <br /> Site Suffix: l 1 0 Routine Q Re-inspection Q Referral Q Observation <br /> Local , /� If Referral,choose referral type(Fill one) <br /> Identifier: (\�ui(l I\ C D Ll(�( Q CHP Q CalRecycle Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name <br /> Q 1 Inspected By Inspector <br /> Physical AdCJr}� t.' T\1e U � �\lnu_,1 `J I�S(0 U�1T f-�V <br /> 3 1 <br /> x53'1 Wak,c�oo � - I <br /> Sk <br /> Inspection Date 1 VV <br /> Time In Time out <br /> Business Rep Title l 0 AM l r'� 0 AM <br /> I �*' • � � <br /> Sb c oPM � 1 �/ ® PM <br /> r- ��1u� C7w�,er - <br /> -- - - - - Operational Status Tire Type Business Role Storage Type <br /> Tire Count (Whole/PTE) Q O (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> ® Active e Passenger • Generator 0 Outdoor <br /> O Q Closed Q Altered <br /> GPS Latitude Q Hauler ® Indoor <br /> O Q Inactive Q Truck <br /> Longitude - Q Planned Q OTR Q End-Use Q Container <br /> Business Type(Fill all that apply) <br /> ® New Tire Dealer Q Auto Repair Q Trucking Fleet Q Government Q Retreader Q Dismantler Q Tire Derived Fuel <br /> 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 Q - Q Notice Of Violation Q Extension <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 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 a <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 o <br /> Q Q 14 CCR§18460.2-Manifest System Requirements for Registered Waste Tire Haulers Q Referred/CalRecycle Enforcement <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 <br /> In Compliance-No Violations o <br /> Q Q Other:§ <br /> - - z <br /> Comments W t rain ,f1 S G u _L <br /> Noyiolw�iMs « lCL'us a4- c�nc�rn <br /> Inspection Form Included: Q Au <br /> -Comments Included: —����`- �„jJ� <br /> Business Rep's Signature Phone Number Insp or's Signature Phone Number <br /> INSTRUCTIONS ON BACK Correct:0 Incorrect: X *� q EXAMPJLJEJ 1112 3 62081 <br /> ■ White Copy:CalRecycle Yellow Copy:Operator Pink Copy:LEA ® ■ <br />