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Waste Tire SuliBey & Inspection Report Inspection Report Number <br /> CalRecycle State of California <br /> CalRecycle 181(Rev.10/10) Survey Form - Page 1 11 - 1210195 <br /> Dept.of Resources Recycling and Recovery(CalRecycle) <br /> Part A-Survey BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- ID <br /> nspection Type(Fill one) <br /> Suffix:Site ` 3 -7 3 S Q I Routine Q Re-inspection Q Referral Q Observation <br /> Local If Referral,choose referral type(Fill one) <br /> C � oCHP CalRecycleo Complaint oEducational Visit 0OtherIdentifier ��� <br /> Business or Facility Name Inspected By Inspector <br /> CO Q)���7 5; fie. '�-r\"-x s 3 9 - � o � ,M ,�1�' v <br /> Physical Address <br /> (o -7s2 �� �Ma11Y, <br /> Inspection Date / / E / <br /> Time In Time Out <br /> Business Rep Titlet t l • AM AM <br /> 0 • '1 d Q PM ' Z O PM <br /> 3-,%,V1/� V {� O 2 1 Operational Status Tire Type Business Role Storage Type <br /> Tire Count (Whole/PTE) 1 O (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> • Active Q Passenger 0 Generator 0 Outdoor <br /> O Q Closed Q Altered <br /> GPS Latitude Q Hauler Q Indoor <br /> O Q Inactive Q Truck <br /> Longitude - Q Planned 0 OTR o End-Use Q Container <br /> Business Type(Fill all that apply) F4" <br /> Q New Tire Dealer Q Auto Repair Q Trucking Fleet Q Government Q Retreader 0 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 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 0 Extension <br /> Q Q 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 o 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 EXT) N <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 O Referred/CalRecycle Enforcement <br /> a <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 1 Q 1 Other:§ <br /> Comments <br /> ��k�v� ��s� �.�� '.�•5� ��;oT vie_ �y��,�,As �.a�e �, <br /> :v c <br /> Inspection Form Included: <br /> ' ` <br /> Comments Included: 0 /—•L <br /> usiness Rep's Signature Phone Number Inspector's Signature Phone Number <br /> -- --- _ 62081 <br /> INSTRUCTIONS ON BACK Correct: Incorrect: �1W E X A M P L E 1 2 3 <br /> ■ White Copy:CalRecycle Yellow Copy:Operator Pink Copy:LEA ® ■ <br />