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0 Waste Tire Sup oey & Inspection Report inspection Report Number ■ <br /> CalRec cle State of California — <br /> Y CalRecycle 181(Rev.10/10) Survey Form - ale 1 I1 1196544 <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-7 � � 1 � - O � Inspection Type(Fill one) <br /> Site Suffix: b 0 Routine 0 Re-inspection 0 Referral 0 Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier: JC V Cd�.n 0 CHP 0 CalRecycle 0 Complaint 0 Educational Visit 0 Other <br /> Business or Facility Name 1 Inspected By Inspector <br /> Physical Ad ess <br /> -72 0 7 5, J act Tdvve. <br /> Inspection Date <br /> Time In Time Out <br /> Business Rep TitleC O AM O AM <br /> _ 1 J O a PM O 0 PM <br /> Operational Status Tire Type Business Role Storage Type <br /> Tire Count (Whole/PTE) 35 (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> 7 * Active 0 Passenger 0 Generator 0 Outdoor <br /> 0 Closed 0 Altered <br /> Ca�� Latitude 0 Hauler 0 Indoor <br /> O 0 Inactive 40 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 <br /> PRC§42951 -Waste Tire Hauler Registration and Transport of Tires <br /> 0 0 PRC§42953-Contracts with Registered Waste Tire Haulers. Compliance Deadline <br /> PRC§42956-Registration/Decal in Vehicle <br /> 0 0 14 CCR§18459-Responsible Entities Complying with Manifesting Requirements Date M / 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 g <br /> Lu <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 join Compliance-No Violations o <br /> 0 0 Other:§ <br /> Comments <br /> N, <br /> \o`_Q taS cs rc.� <br /> Inspection FormIncluded: 0 t <br /> Comments Included: <br /> usm s s Signature Phone Number Inspecto 's Signature Phone Number <br /> }� <br /> INSTRUCTIONS ON BACK Correct:* Incorrect: �C EXAMPLE 1 1 3 62081 <br /> ■ White Copy:CalRecycle Yellow Copy:Operator Pink Copy:LEA ® ■ <br />