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Waste Tire S#Ve & Inspection Re o�lnspection Report Number <br /> CalRecycle State of California Y <br /> CalRecycle 181(Rev.10/10) I1 - 1242520 <br /> Dept.of Resources Recycling and Recovery(CalRecycle) Survey Form - Page 1 BLUE OR BLACK INK PEN <br /> Part A-Survey <br /> Business Profile Inspection Details <br /> TPID- © ' Inspection Type(Fill one) <br /> Site Suffix: ` jj 1 '*-Routine 0 Re-inspection 0 Referral 0 Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier: 5O1{) 13—OMU11t J� (HIAA I'tj 0 CHP 0 CalRecycle 0 Complaint 0 Educational Visit 0 Other <br /> Business or Facility Name Inspected By Inspector <br /> je, �1 A C <br /> s jam, <br /> Physical Ad3 - 1 0 ) cs wffo <br /> Add s <br /> 113CDd ou�a.nt M, <br /> Inspection Date <br /> C` Time In Time Out f -! <br /> Business Rep Title �n 5 0 AM <br /> S ® 0 AM <br /> PM 3 3 ® 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 /> ® Active 0 Passenger • Generator 0 Outdoor <br /> 0 Closed 0 Altered <br /> GPS Latitude 0 Hauler 0 Indoor <br /> 0 0 Inactive Q 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 0 Other 1)3k ?1OA4.a ul <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 <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 /> Lu <br /> 0 0 14 CCR§18461 -Manifest System Requirements for Waste Tire End-Use Facilities u, <br /> 0 0 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators O In Compliance-No Violations o <br /> 0 0 Other:§ <br /> Comments 2 � .���"LA Q,0!�) ��1 ��GL I PJ �1�(� l��Q► <br /> -�A w AX!> 0 l A)14 S 10 ou <br /> N n �g1, �;mss 1' �AreeAs 0+ c_,on(cr4n . <br /> Inspection Form Included: 0 <br /> Comments Included: ® -'+- <br /> *ines*sepW's Sig Nnatur9gl Phone Number Insp toy's Signature Phone Number <br /> 62081 <br /> INSTRUCTIONS ON BACK Correct: Incorrect: EXAM 1 2 3 <br /> White Copy:CalRecycle Yellow Copy:Operator Pink Copy: <br />