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Waste Tire vey & Inspection Repoi Inspection Report Number <br /> CalRecycle CalRecycle <br /> (a I 1 - 1176711 <br /> CalRecycle 181(Rev.10/10) <br /> y(Cal Survey Form - Page 1 <br /> Dept of Resources Recycling and Recovery(CalRecycle) <br /> Part A-SurveyBLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- t Inspection Type(Fill one) <br /> Site Suffix: I © © g 0 I ® Routine 0 Re-inspection 0 Referral 0 Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier: �CC1,Cf i✓L� IlNl.l�l t 0 CHP 0 CalRecycle 0 Complaint 0 Educational Visit 0 Other <br /> Business or Facility Name 1 / Inspected By Inspector <br /> �cti x_. V)/A G(Z'Ill't, <br /> Physical Address — I <br /> C� ' <br /> Inspection Date <br /> Time In ( Time Out <br /> Business Rep Title ®AM O AM <br /> �a ( �9c)s �- S,� ilc vt -I 3 � O PM C Z � C) 5 O PM <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 /> / 0 46 Active <br /> 0 Passenger g a Generator 4& Outdoor <br /> GapS Latitude O0 Closed0 Altered Hauler <br /> -Q-Indoor---- <br /> 0 0 Inactive ® Truck <br /> Longitude - 0 Planned ® OTR 0 End-Use 0 Container <br /> Business Type(Fill all that apply) <br /> 0 New Tire Dealer 0 Auto Repair Trucking Fleet 0 Government 0 Retreader 0 Dismantler 0 Tire Derived Fuel <br /> 0 Used Tire Dealer 0 Auto Body 0 Car Dealer 0 Collection 0 Crumb Rubber <br /> 0 Service Station 0 Hauler 0 Agriculture 0 Shredder 0 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 /> 0 Notice Of Violation 0 Extension <br /> 0 0 PRC§42951 -Waste Tire Hauler Registration and Transport of Tires <br /> 0 0 PRC§42953-Contracts with Registered Waste Tire Haulers. Compliance Deadline <br /> 0 0 PRC§42956-Registration/Decal in Vehicle <br /> 0 0 14 CCR§18459-Responsible Entities Complying with Manifesting Requirements Date <br /> 0 0 14 CCR§18459.1 -Tire Program ID Number from CalRecycle N <br /> 0 0 14 CCR§18459.2.1 -Submittal of Comprehensive Trip Logs within 90 days (Required for NOV or EXT) N <br /> 0 0 14 CCR§18459.3-Retention of Comprehensive Trip Logs for 3 years o <br /> 0 0 14 CCR§18460.2-Manifest System Requirements for Registered Waste Tire Haulers 0 Referred/CalRecycle Enforcement <br /> 0 0 14 CCR§18461 -Manifest System Requirements for Waste Tire End-Use Facilities w <br /> 0 0 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators ®In Compliance-No Violations o <br /> 0 0 Other:§ <br /> Comments <br /> Inspection Form Included: 03'A4_ _ <br /> Comments Included: ® I <br /> ;Business Rep's gnature Phone Numbignature Phone Number <br /> INSTRUCTIONS ON BACK COrrec#: Incorrect; ( L 1 2 31 62081 <br /> White Copy:CalRecycle Yellow Copy:Operator Pink C py: <br />