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Waste Tire & _rey & Inspection Report nspection Report Number <br /> ® <br /> CalRecycle State of California — <br /> CalRecycle 181(Rev.10/10) Survey Form - Page 1 I 1 117 6 6 u 9 <br /> Dept.of Resources Recycling and Recovery(CalRecycle) <br /> Part A-Survey BLUE OR BLACK INK PEN <br /> iness Profile Inspection Details <br /> ..-1D- Inspection Type(Fill one) <br /> Site Suffix: 00 0 5- Z Z - 0 r ® Routine O Re-inspection O Referral Q Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier: n O CHP O CalRecycle O Complaint O Educational Visit Q Other <br /> Business or Facility Name Inspected By Inspector <br /> Phys'cAddre s <br /> Inspection Date © / 2 1 / t <br /> Slz-,c l�fz�r CA <br /> Time In Time Out <br /> Business Rep Title ` ® AM ® AM <br /> I�/ 10 PM 3 � 0 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 /> Q Active Q Passenger Q Generator Q Outdoor <br /> O <br /> GPS Latitude ® Closed Q Altered O Hauler Q Indoor <br /> O Q Inactive Q Truck <br /> Longitude - O Planned Q OTR O End-Use Q Container <br /> Business Type(Fill all that apply) <br /> New Tire Dealer Q Auto Repair Q Trucking Fleet Q Government Q Retreader Q Dismantler Q Tire Derived Fuel <br /> Used Tire Dealer Q Auto Body Q Car Dealer Q Collection Q Crumb Rubber <br /> Q Service Station Q Hauler Q Agriculture Q Shredder Q Other <br /> Part B - Inspection of Waste Tire Dealer, Generator, Hauler and End-Use Facility ENFORCEMENT STATUS <br /> — - --- -- <br /> V A HAULING AND MANIFEST REQUIREMENTS <br /> --- - --- — — - - --- O Notice Of Violation Q Extension <br /> O O PRC§42951 -Waste Tire Hauler Registration and Transport of Tires <br /> O O PRC§42953-Contracts with Registered Waste Tire Haulers. Compliance Deadline <br /> O O PRC§42956-Registration/Decal in Vehicle <br /> O O 14 CCR§18459-Responsible Entities Complying with Manifesting Requirements Date m / m / m <br /> Q Q 14 CCR§18459.1 -Tire Program ID Number from CalRecycle a <br /> (Required for NOV or EXT) <br /> Q 0 14 CCR§18459.2.1 -Submittal of Comprehensive Trip Logs within 90 days N <br /> r <br /> O O 14 CCR§18459.3-Retention of Comprehensive Trip Logs for 3 years o <br /> O O 14 CCR§18460.2-Manifest System Requirements for Registered Waste Tire Haulers Q Referred/CalRecycle Enforcement <br /> O O 14 CCR§18461 -Manifest System Requirements for Waste Tire End-Use Facilities W <br /> O O 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators ®In Compliance-No Violations <br /> 10 1 0 <br /> Comments <br /> _;pection Form Included: 0 <br /> Comments Included: �� <br /> B /� <br /> Business Rep's Signature Phone Number Inspector's Signature Phone Number <br /> INSTRUCTIONS ON BACK Correct:* Incorrect:Incorrect:� E X A M L 112 3 62081 <br /> White Copy:CalRecycle Yellow Copy:Operator Pink Copy: <br />