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Waste Tire Survey & Inspection Report Inspection Report Number ■ <br /> CalRecycle state of California <br /> CalRecycle 181(Rev.10/10) Survey Form - Page 1 11 - 1210243 <br /> Dept of Resources Recycling and Recovery(CalRecycle) <br /> Part A-Survey BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- Inspection Type(Fill one) <br /> Site Suffix: o� l 1 `j �} ® Routine Q Re-inspection Q Referral Q Observation <br /> Local _ If Referral,choose referral type(Fill one) <br /> Identifier: SPAN, �ock% k., CCA, Q CHP Q CalRecycle Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name Inspected By Inspector <br /> Physical Address " 99 <br /> l 1 r Kj ��J�� <br /> a I Sl PLC14,1_171 A-v2-- V - <br /> Inspection Date 6 / e_) <br /> GA 45'610-1 <br /> Time In Time Out <br /> Business Rep Title O AM O AM <br /> s 4s- ® PM , ® 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 If Passenger It Generator OpOutdoor <br /> O Q Closed Q Altered <br /> GPS Latitude Q Hauler Q Indoor <br /> O Q Inactive Q Truck <br /> Longitude - Q Planned Q OTR Q End-Use Q Container <br /> Business Type(Fill all that apply) <br /> Q New Tire Dealer Q Auto Repair Q Trucking Fleet Q Government Q Retreader Q Dismantler Q Tire Derived Fuel <br /> Q Used Tire Dealer Q Auto Body Q Car Dealer Q Collection Q Crumb Rubber <br /> Q Service Station Q Hauler Q Agriculture Q Shredder ® Other lam'/yllti!/Y� <br /> Part B - Inspection of Waste Tire Dealer, Generator, Hauler and End-Use Facility ENFORCEMENT STATUS <br /> V A HAULING AND MANIFEST REQUIREMENTS <br /> Q Notice Of Violation Q Extension <br /> Q Q <br /> PRC§42951 -Waste Tire Hauler Registration and Transport of Tires <br /> Q Q PRC§42953-Contracts with Registered Waste Tire Haulers. Compliance Deadline <br /> PRC§42956-Registration/Decal in Vehicle <br /> Q Q 14 CCR§18459-Responsible Entities Complying with Manifesting Requirements Date <br /> Q Q 14 CCR§18459.1 -Tire Program ID Number from CalRecycle <br /> Q Q 14 CCR§18459.2.1 -Submittal of Comprehensive Trip Logs within 90 days (Required for NOV or EXT) <br /> Q Q 14 CCR§18459.3-Retention of Comprehensive Trip Logs for 3 years o <br /> Q Q 14 CCR§18460.2-Manifest System Requirements for Registered Waste Tire Haulers Q Referred/CalRecycle Enforcement <br /> LU <br /> LU <br /> Q Q 14 CCR§18461 -Manifest System Requirements for Waste Tire End-Use Facilities <br /> Q Q 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators In Compliance-No Violations o <br /> Q Q Other:§ _ <br /> Comments <br /> Inspection FormIncluded: Q I <br /> Comments Included: ® a ` Sld t <br /> siness 's Si re Pho e N tuber s c or' S' nature Phone Number <br /> 62081 <br /> INSTRUCTIONS ON BACK ��orrect:0 Incorrect: E A MtnL 1 2 3 <br /> ■ White Copy:CalRecycle Yellow Copy:Operator Pink Copy LE ® 0 <br />