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Waste Tire ?Rey & Ins ection Re o�Inspection Report Number <br /> CalRecycle State of California — <br /> CalRecycle 181(Rev.10/10) Survey Form - Mage 1 I1 1242316 <br /> Dept of Resources Recycling and Recovery(CalRecycle) <br /> Part A-Survey BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- I A `' 3 m p� Inspection Type(Fill one) <br /> Site Suffix: _1 V ( 40 Routine Q Re-inspection Q Referral Q Observation <br /> LocalIf Referral,choose referral type(Fill one) <br /> Identifier: f1 �0��u LAA' 1� Q CHP Q CalRecycle Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name I Inspected By Inspector <br /> �M0_V, S 3 - l 0 1 aCOTT o <br /> Physical Address <br /> Inspection Date / <br /> oc�kor, (,� �1SZID I <br /> Time In Time Out <br /> Business Rep Title 3 O AM j� O AM <br /> Swi ar U O PM D e PM <br /> Ass i 4 44 6)[tPk er <br /> Operational Status Tire Type Business Role Storage Type <br /> Tire Count(Whole/PTE) T'I 1 (_ (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> ® Active a Passenger ® Generator Q Outdoor <br /> O Q Closed Q Altered <br /> GPS Latitude Q Hauler ID 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 /> e 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 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 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 /> QQ 14 CCR§18459-Responsible Entities Complying with Manifesting Requirements Date <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 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 _ 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 <br /> V v{lib � ���'� �� �U �On ���►'}'1�.� �-1,T � G.�CJI �� <br /> IVD45 hr A feuSrc�� U?01 W <br /> Inspection Form Included: Q I <br /> Comments Included: ® <br /> B siness Rep's.Signature Phone Number Insp c or's Signature Phone Number <br /> INSTRUCTIONS ON BACK Correct:40 Incorrect: E X A WL <br /> 1 2 3 62081 <br /> 0 White Copy:CalRecycle Yellow Copy:Operator Pink Co © ■ <br />