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0 Waste Tire Su,Bey & Inspection Report Inspection Report Number ■ <br /> CalRecycle State of California I 1 @ 121013 <br /> CalRecycle 181(Rev.10/10) SurVe�/ Form - Page 1 <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 Type(Fill one) <br /> Site Suffix: 6 5 5 t� 1 0 Routine 0 Re-inspection 0 Referral 0 Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier: ��� �r,n��f� VA' 0 CHP 0 CalRecycle 0 Complaint 0 Educational Visit 0 Other <br /> l — <br /> Business or Facility Name Inspected By ` h Inspector <br /> Physical <br /> dress Vf� SCJ S 2 CI - 1 1 <br /> dd / M <br /> n Inspection Date <br /> (,A 9SZos <br /> Time In Time Out <br /> Business Rep Title * AM C AM <br /> c�eeca�Oen$ \ 0 • S O Q PM 0 PM <br /> �c�aY. 0 Lc� :�n lea" -CCS c- <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 /> fr Active 0 Passenger 0 Generator 0 Outdoor <br /> 0 0 Closed 0 Altered Jl <br /> v/ <br /> GPS Latitude 0 Hauler 0 Indoor <br /> O Q Inactive 0 Truck <br /> Longitude - 0 Planned 0 OTR 0 End-Use 0 Container <br /> Business Type(Fill all that apply) Poo*tI% <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 /> PRC§42956-Registration/Decal in Vehicle <br /> 0 0 14 CCR§18459-Responsible Entities Complying with Manifesting Requirements Date m <br /> 0 0 14 CCR§18459.1 -Tire Program ID Number from CalRecycle a <br /> 0 0 14 CCR§18459.2.1 -Submittal of Comprehensive Trip Logs within 90 days (Required for NOV or EJ(T) <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 0 In Compliance-No Violations o <br /> 0 0 Other:§ <br /> \ - z <br /> Comments ������ \�-S� �<'-� ��(�.Sp�-�`��Ove, �•,' C�� �S � <br /> r c <br /> Inspection Form Included: 0 (�6g_ 2 �y <br /> Comments Included s ': r w idq-a�7 L7 �~ d <br /> Business Repnature Phone Number Inspe or's Signature Phone Number <br /> INSTRUCTIONS ON BACK Correct: Incorrect: � W EXAMPLE 1112 3 62081 <br /> ■ White Copy:CalRecycle Yellow Copy:Operator Pink Copy:LEA ® ■ <br />