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0 Waste Tireey & Inspection Repor Inspection Report Number <br /> ca Y C1e State of California <br /> CalRecycle 181(Rev.10/10) Survey Form - Page 1 I1 - 1. 176598 <br /> Dept.of Resources Recycling and Recovery(CalRecycle) <br /> Part A-Survey BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- Inspection® I Inspection Type(Fill one) <br /> Site Suffix: ® Routine 0 Re-inspection 0 Referral 0 Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier: '� r C. 0 CHP 0 CalRecycle 0 Complaint 0 Educational Visit 0 Other <br /> Business or Facility Name Inspected By Inspector <br /> "???/)/J f <br /> Physical Address <br /> 4. <br /> J�c.(� - <br /> Inspection Date <br /> Time In Time Out <br /> Business Rep Title L` ® AM 0 AM <br /> W S T D QPM © O ® PM <br /> iSOY <br /> Operational Status Tire Type Business Role Storage Type <br /> Tire Count (Whole/PTE) ` 1 (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> ® Active ® Passenger ® Generator 0 Outdoor <br /> Latitude 0 Closed 0 Altered <br /> GP$ 0 Hauler Indoor <br /> O 0 Inactive 0 Truck <br /> Longitude - 0 Planned 0 OTR 0 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 • 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 m / m <br /> 0 0 14 CCR§18459.1 -Tire Program ID Number from CalRecycle <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 /> 2 <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 (9 In Compliance-No Violations o <br /> 0 1 0 1 Other:§ <br /> Comments q4 , th <br /> I LiA IA/le.0 IAC2Its <br /> Inspection Form Included: 0 <br /> Comments Included: <br /> Business Rep's Si nature Phone Number ector's Signature Phone Number <br /> INSTRUCTIONS ON BACK Correct j Incorrect k � ]JEJXAMP L E 1 2 3 62081 <br /> White Copy:CalRecycle Yellow Copy:Operator Pink Copy:LFA <br />