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Waste Tire Ed& & Inspection Repot spection Report Number <br /> CalRecycle State of California Y <br /> CalRecycle 181(Rev.10/10) Survey Form - Page 1 11 - 1176640 <br /> Dept.of Resources Recycling and Recovery(CalRecycle) <br /> Part A-Survey <br /> BLUE OR BLACK INK PEN_ <br /> Business Profile Inspection Details <br /> TPID- Inspection Type(Fill one) <br /> Site Suffix: 1 t-} 4 Q 0 0 Routine Q Re-inspection Q Referral Q Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier: SC141-1 ?AP6AA-VX Ca"A Q CHP Q CalRecycle Q Complaint Q Educational Visit Q Other <br /> Business or Facility Nam <br /> Inspected By Inspector <br /> Physical Address 3 ( 0 Am aV1. A &R�-cA— <br /> Inspection Date c) / t4 / r / <br /> �rrcc� CA X15 37(o <br /> Time In Time Out <br /> Business Rep Title O AM O AM <br /> 0 ® pM Q ;2 Q ® 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 Active Q Passenger 0 Generator Q Outdoor <br /> O Q Closed Q Altered <br /> GPS Latitude Q Hauler ® Indoor <br /> O Q Inactive ® Truck <br /> Longitude - Q Planned Q OTR Q End-Use Q Container <br /> Business Type(Fill all that apply) <br /> Q New Tire Dealer Q Auto Repair ® 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 [HAWING AND MANIFEST REQUIREMENTS <br /> -- <br /> Q Q PRC§42951 -Waste Tire Hauler Registration and Transport of Tires Q Notice Of Violation Q Extension <br /> I <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 m / M m <br /> Q Q 14 CCR§18459.1 -Tire Program ID Number from CalRecycle N <br /> Q Q 14 CCR§18459.2.1 -Submittal of Comprehensive Trip Logs within 90 days (Required for NOV or EX7) <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 /> LU <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 ®In Compliance-No Violations o <br /> Q Q Other:§ <br /> Comments y� - <br /> 1 ' <br /> Inspection Form Included: Qj /�pg) <br /> 46'8-016�3 <br /> Comments Included. <br /> Busine ep's Signature Phone Number Inspector's Signature Phone Number <br /> INSTRUCTIONS ON BACK Correct:* Incorrect: �/_ E X I A L 1 1 (2 3 62081 <br /> White Copy:CalRecycle Yellow Copy:Operator Pink Co y:L LA <br />