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■ Inspection Report Number <br /> � Waste Tire Survey & Inspection Report � <br /> CalRecycle state of California <br /> Y CalRecycle 181(Rev.10/10) Survey Form - Page 1 I1 1226324 <br /> Dept.of Resources Recycling and Recovery(CalRecycle) <br /> Part A-Survey _ —__ BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- QInspection Type(Fill one) <br /> Site Suffix: ' �p l 0 Routine 0 Re-inspection 0 Referral 0 Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier: S c1,n J U l�1/ Ch t,(\`�U 0 CHP 0 CalRecycle 0 Complaint 0 Educational Visit 0 Other <br /> Business or Facility Name <br /> J IV Inspected By Inspector <br /> nIC �� I <br /> Physical Address Fir�, - t C�edd <br /> x4US <br /> - IT - <br /> Jr�` i Inspection Date <br /> t A Time In Time Out <br /> Business Rep Title j� /� O AM ? �> 0 AM <br /> 3 ' v is PM ' J v 0 PM <br /> 1' <br /> --- <br /> -- -- - Operational Status Tire Type Business Role Storage Type <br /> Tire Count (Whole/PTE) 16 / (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> 0 Active ® Passenger 0 Generator 0 Outdoor <br /> O 0 Closed 0 Altered <br /> GPS Latitude _ 0 Hauler 0 Indoor <br /> O 0 Inactive ® Truck <br /> Longitude - 0 Planned 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 A . �ePu;f JV�O p <br /> Part B - Inspection of Waste Tire Dealer, Generator, Hauler and End-Use Facility ENFORCEMENT STATUS <br /> V A HAULING AND MANIFEST REQUIREMENTS <br /> Q Notice Of Violation 0 Extension <br /> O O <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 /> a <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 /> S <br /> W <br /> 0 0 14 CCR§18461 -Manifest System Requirements for Waste Tire End-Use Facilities <br /> 0 0 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators 0 In Compliance-No Violations o <br /> 0 0 Other:§ _ <br /> Comments �-- <br /> _1!4 <br /> - - Ste, <br /> Inspection Form Included: 0 <br /> Comments Included: ® "Rep's <br /> --�1+— z'—� �a _ I' <br /> Busgnature Phone Number Inspe is Signature one Number <br /> INSTRUCTIONS ON BACK Correct:0 Incorrect: EXAM 1 2 3 62081 <br /> ■ White Copy:CalRecycle Yellow Copy:Operator Pink Copy. ® ■ <br />