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2 Waste Tireey & Inspection Repoi Inspection Report Number <br /> CalRecycle State of California <br /> CalRecycle 181(Rev.10/10) Survey Form - Page 1 11 - 1176581 <br /> Recycle) <br /> Dept.of Resources Recycling and Recovery(Cal <br /> Part A_ - Survey BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- 5 L, _ b I Inspection Type(Fill one) <br /> Site Suffix: ® Routine Q Re-inspection Q Referral Q Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier: Q CHP Q CalRecycle Q Complaint Q Educational Visit Q Other <br /> Busines <br /> s or Facility Name 1 U // Inspected By Inspector <br /> Br-f+ -Z- <br /> Physical Address 3 <br /> Inspection Date <br /> Time In Time Out <br /> Business Rep Title / ♦AM f 1, 49 AM <br /> Q PM O 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 /> Q Active Q Passenger Q Generator Q Outdoor <br /> O ® Closed Q Altered <br /> GPS Latitude Q Hauler Q 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 /> Q 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-7—kV-7-k7l 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 /> 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 q <br /> Q Q 14 CCR§18459.2.1 -Submittal of Comprehensive Trip Logs within 90 days (Required for NOV or EXE <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 /> 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 wY�' : �� --�H �� -��:�ttl <br /> nc rst 7sw r <br /> Inspection Form Included: Q x <br /> Comments Included: - <br /> Business ep's Slgnatu a Phone Number 'Inspector's Signature Phone Number <br /> INSTRUCTIONS ON BACK Correct: Incorrect: y _ EXAMPLE 62081 1 2 3 <br /> -- - <br /> White Copy:CalRecycle Yellow Copy:Operator Pink Copy:LEA <br />