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Waste Tire Su, ✓ey & Inspection Repon Inspection Report Number <br /> State of California <br /> CalRecycle <br /> CalRecycle 181(Rev.10/10) Survey Form - Page 1 I1 - 1176759 <br /> Dept.of Resources Recycling and Recovery(CalRecycle) <br /> Part A-Survey <br /> BLUE-OR_ BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- Inspection Type(Fill one) <br /> Site Suffix: l ® Routine 0 Re-inspection 0 Referral 0 Observation <br /> Local �^ If Referral,choose referral type(Fill one) <br /> C <br /> Identifier: save ��-trb✓�� OL'yl' '% 0 CHP 0 CalRecycle 0 Complaint 0 Educational Visit 0 Other <br /> Business or Facility Name l Inspected By Inspector <br /> s <br /> Physical Address <br /> f G �J, <br /> Inspection Date / 1 9 / L <br /> CA 5_-e4,eq Time In Time Out <br /> Business Rep ( Title9 <br /> ®AM 0 AM <br /> C> O PM L � ' D ��PM <br /> r 1 Ic-Ir� � Dc,�nG y Operational Status Tire Type Business Role Storage Type <br /> (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> Tire Count(Whole/PTE) <br /> ® Active • Passenger 0 Generator ® Outdoor <br /> O 0 Closed 0 Altered <br /> GPS Latitude 0 Hauler ® Indoor <br /> O 0 Inactive ® 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 ® 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 <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 /> 0 0 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 EXE <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 ®in Compliance-No Violations o <br /> 0 0 Other:§ <br /> Comments <br /> (,C /' <br /> Sec C22Z '0_�� <br /> Inspection Form Included: 0 9 , f <br /> Comments Included: ® <br /> Business Rep's Signature Phone Number In tor's Agn9dre Phone Number <br /> INSTRUCTIONS ON BACK Correct:* Incorrect: X � E X A L 11 o 62081 <br /> 1 2 3 <br /> ■ White Copy:CalRecycle Yellow Copy:Operator Pink Cop�L / <br /> © ■ <br />