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Waste Tire ,' vey & Inspection Repol Inspection Report Number ■ <br /> CalRecycle State of California I 1 - 1196355 <br /> CalRecycle 181(Rev.10/10) Survey Form - Page 1 <br /> Dept.of Resources Recycling and Recovery(CalRecycle) <br /> Part A Survey <br /> - - -- -- --BLUE-OR-BL-ACK-INK-PEN <br /> Business Profile Inspection Details <br /> TPID- Inspection I b - O Inspection Type(Fill one) <br /> Site Suffix: 7 ® Routine Q Re-inspection Q Referral Q Observation <br /> Local r-- If Referral,choose referral type(Fill one) <br /> Identifier: Se.n J 0 C I u,n 6U.n' vA 0 CHP 0 CalRecycle 0 Complaint 0 Educational Visit 0 Other <br /> Business or Facility Name Inspected By Inspector <br /> Physical Address I 1 �S (_0 b <br /> Lin ne- <br /> Inspection Date <br /> Time In Time Out <br /> Business Reep, Title e1 L r� 0 �l 0 AM 0 AM <br /> 9�_6kIl T-(1Uf'nzy n PIC) LlU 1 bn t► � r V ® PM � � v ® PM <br /> Operational Status Tire Type Business Role Storage Type <br /> Tire Count(Whole/PTE) <br /> (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> !� <br /> ® Active O Passenger 0 Generator 0 Outdoor <br /> 0 Closed 0 Altered N <br /> GPS Latitude 0 Hauler 0 Indoor" q <br /> O Q Inactive 11 Truck <br /> Longitude - O Planned ® OTR O End-Use 0 Container <br /> Business Type(Fill all that apply) <br /> 0 New Tire Dealer 0 Auto Repair 0 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 4D Other Gfw tL Mqf14f-MC+R feJ- <br /> Part B - Inspection of Waste Tire Dealer, Generator, Hauler and End-Use Facility ENFORCEMENT STATUS <br /> V A HAULING AND MANIFEST REQUIREMENTS <br /> O O PRC§42951 -Waste Tire Hauler Registration and Transport of Tires Q Notice Of Violation Q Extension <br /> O O PRC§42953-Contracts with Registered Waste Tire Haulers. Compliance Deadline <br /> O O PRC§42956-Registration/Decal in Vehicle <br /> O O 14 CCR§18459-Responsible Entities Complying with Manifesting Requirements Date <br /> O Q 14 CCR§18459.1 -Tire Program ID Number from CalRecycle N <br /> O Q 14 CCR§18459.2.1 -Submittal of Comprehensive Trip Logs within 90 days (Required for NOV or EXE N <br /> a <br /> 0 0 14 CCR§18459.3-Retention of Comprehensive Trip Logs for 3 years o <br /> O O 14 CCR§18460.2-Manifest System Requirements for Registered Waste Tire Haulers 0 Referred/CalRecycle Enforcement <br /> O O 14 CCR§18461 -Manifest System Requirements for Waste Tire End-Use Facilities W <br /> O O 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators S In Compliance-No Violations o <br /> O O Other:§ <br /> Comments <br /> 11 L 'b <br /> ov. <br /> Nz--violonL (3� 11 ["'Qt (A Wnurn- <br /> Inspection Form Included: 0 <br /> Comments Included: ® L., <br /> - I'd <br /> Business Rep's Signature Phone Number Insp tor's Signature Phone Number <br /> �,( <br /> INSTRUCTIONS ON BACK Correct:18 Incorrect: NJ E X A M P L E 1 62081 2 3 <br /> ■ White Copy:CalRecycle Yellow Copy:Operator Pink Copy:LEA <br />