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Waste Tire Su. rey & Inspection Report Inspection Report Number ■ <br /> CalRecycle state of California I 1 1210452 <br /> CalRecycle 181(Rev.10"0) Survey Form - Page 1 <br /> Dept.of Resources Recycling and Recovery(CalRecycle) <br /> Part A-Survey BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- 1 � � n a 3 r � � © 1 Inspection Type(Fill one) <br /> Site Suffix: b ) ® Routine Q Re-inspection Q Referral Q Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier OtA�I �' <br /> r. '&%() CUtil1 O CHP Q CalRecycle Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name L Inspected By Inspector <br /> _�rU\j�n 7b 1J5 , -Iq _ - U <br /> Physical Address l CSLUIT0 <br /> a\2-010 f",s cn CA <br /> Inspection Date <br /> Time In Time Out <br /> Business Rep L Titlec I O 40 AM <br /> V H SrLL1��eI O'3�1�L2 m jlC• v O PM QPM <br /> 1 Operational Status Tire Type Business Role Storage Type <br /> Tire Count (Whole/PTE) 1 p O (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> ' I O 41 Active 41 Passenger ® Generator ® Outdoor <br /> O Q Closed O Altered <br /> GPS Latitude Q Hauler Q Indoor <br /> O Q Inactive 41 Truck <br /> Longitude - Q Planned • OTR O 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 l 1 <br /> Q Service Station Q Hauler Q Agriculture Q Shredder 41 Other Trai -4,c- cA SC{l�S <br /> Part B - Inspection of Waste Tire Dealer,Generator, Hauler and End-Use Facility ENFORCEMENT STATUS <br /> V A HAULING AND MANIFEST REQUIREMENTS <br /> O O PRC§42951 -Waste Tire Hauler Registration and Transport of Tires Notice Of Violation Extension <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 <br /> O O 14 CCR§18459.1 -Tire Program ID Number from CalRecycle <br /> Q O 14 CCR§18459.2.1 -Submittal of Comprehensive Trip Logs within 90 days (Required for NOV or EXT) n <br /> Q Q 14 CCR§18459.3-Retention of Comprehensive Trip Logs for 3 years <br /> Q O 14 CCR§18460.2-Manifest System Requirements for Registered Waste Tire Haulers Q Referred/CalRecycle Enforcement <br /> 0 O 14 CCR§18461 -Manifest System Requirements for Waste Tire End-Use Facilities W <br /> O Q 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators <br /> in Compliance-No Violations o <br /> Q 1 O Other:§ <br /> Comments 1 < <br /> oCL4. <br /> L,As_nokwl <br /> J i D��vnS C�J��e��c�s4-C,�nCe�sn• <br /> Inspection Form Included: <br /> Comments Included: * <br /> Business R 's Signature k Phone Number Insp is Signature Phone Number <br /> INSTRUCTIONS ON BACK Correct:* Incorrect: EXAMPLE 1 2 3 62081 <br /> N � <br /> ■ White Copy:CalRecycle Yellow Copy:Operator Pink Cop :L © 0 <br />