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Waste Tire SL- grey & Inspection Repor, Inspection Report Number <br /> CalRecycle State of California <br /> Y CalRecycle 181(Rev.10/10) Survey Fora Pale 1 I1 1178034 <br /> Dept of Resources Recycling and Recovery(CalRecycle) <br /> BLUE OR BLACK INK PEN <br /> Part A-Survey <br /> Business Profile Inspection Details <br /> TPID- Inspection Type(Fill one) <br /> Site Suffix: 2 1 L( e t 0 Routine 0 Re-inspection 0 Referral 0 Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier: ✓1 �./1� ' 0 CHP 0 CalRecycle 0 Complaint 0 Educational Visit 0 Other <br /> Business or Facility Name (((( Inspected By Inspector <br /> ~ <br /> Physical Address <br /> /61cO OD , mut mac_ <br /> Inspection Date <br /> Time In AM Time Out <br /> 10 AM <br /> Business Rep Title <br /> 1 <br /> _ / 0 . SS a 0 PM 1 � Z © O 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 Outdoor <br /> GPS Latitude 0 Closed 0 Altered 0 Hauler Indoor <br /> 0 Q 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 Other ejavc✓icv)e— io-tt- Cook,/- <br /> Part B - Inspectiori of Waste Tire Dealer,Generator, Hauler and End-Use Facility ENFORCEMENT STATUS <br /> V A HAULING AND MANIFEST REQUIREMENTS <br /> 0 0 PRQ Notice Of Violation Q Extension <br /> C§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 N <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 EXTJ 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 /> 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 ®In Compliance-No Violations o <br /> 0 0 Other:§ <br /> 6 <br /> Comments <br /> V <br /> Inspection Form Included: 0 <br /> Comments Included: ® <br /> usi ess Rep's Signature Phone Number s c r .Si ature Phone Number <br /> INSTRUCTIONS ON BACK Correct:0 Incorrect: E X A 1 2 3 62081 <br /> :X:*:ql <br /> ■ White Copy:CalRecycle Yellow Copy:Operator Pink C :L ® ■ <br />