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0 Waste Tire Sup Bey & Inspection Report inspection Report Number <br /> CalRecycle State of California — <br /> CalRecycle 181(Rev.10/10) Survey Form - Page 1 I1 1230206 <br /> Dept.of Resources Recycling and Recovery(CalRecycle) <br /> Part A-Survey BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- / m Inspection Type(Fill one) <br /> Site Suffix: �j 3 S l� 0 Routine 0 Re-inspection 0 Referral 0 Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier. � G V`y—, �V — 0 CHP 0 CalRecycle 0 Complaint 0 Educational Visit 0 Other <br /> Business or Facility Name Inspected By Inspector <br /> �_—,VrS ?� - O <br /> Physical Address <br /> - <br /> Inspection Date 1 / l 2 / I <br /> CA 9ss20 <br /> Time In Time Out <br /> Busin ss R �^L Titlell `�Sa �n� 0 AM 0 AM <br /> I y O ® PM <br /> rim. G *PM 1 <br /> - -le Operational Status Tire Type Business Role Stage Type <br /> Tire Count(Whole/PTE) ] t �J (Fill one only) (Fill all that apply) (Fill all that apply) (Fill d that apply) <br /> ( ` ( Active OPPassenger *Genara/or Outdoor 3$ <br /> O 0 Closed 0 Altered <br /> GPS Latitude 0 Hauler M+door 71 <br /> O 0 Inactive 0 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 Trucking Fleet 0 Government 0 Retreader 0 Dismantler 0 Two D Ned 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 0 PRC§42951 -Waste Tire Hauler Registration and Transport of Tires Notice Of vloas0on G lsion <br /> st+en <br /> 0 0 PRC§42953-Contracts with Registered Waste Tire Haulers. Compliance Des 0 <br /> 0 0 PRC§42956-Registration/Decal in Vehicle <br /> 00 14 CCR§18459-Responsible Entities Complying with Manifesting Requirements Date 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 (RequireO h i NOV or EX-7) 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 /> 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 /> Nc� v�p����ovS o c J�c2c�sS p� ��,c.e�✓\ <br /> Inspection Form Included: 0 <br /> IL <br /> Comments lncluded: o (,� <br /> lac <br /> Business Rep's Signature Phone Number Inspe tor's Signature Phone Number <br /> INSTRUCTIONS ON BACK Correct:0 incorrect: 77 �ql EXAMPLE 1 2 3 62081 <br /> ■ White Copy:CalRecycle Yellow Copy:Operator Pink Copy:LEA <br />