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Waste Tire 5L.. ,iey & Inspection Repoit, Inspection Report Number <br /> CalRecycle State of California <br /> Y CalRecycle 181(Rev.10/10) Survey Form - Page 1 11 - 117636111- <br /> Dept.of Resources Recycling and Recovery(CalRecycle) <br /> Part A-Survey _B_L_UE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- Inspection I Inspection Type(Fill one) <br /> Site Suffix: �(, ( * Routine Q Re-inspection Q Referral Q Observation <br /> LocalIf Referral choose referral a Fill one) <br /> l �1 type( <br /> `�� V wl <br /> Identifier: Q CHP Q CalRecycle Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name <br /> Inspected By Inspector <br /> �� 5 �ess ���- pai <br /> Phys, ddrr S 5 - I o 1 <br /> gen Eseo& <br /> x.3.2 X1 N . (�of)A PT <br /> CV(l�i�V" <br /> Lo d"llC5)mi Inspection Date 7"` Time In Time Out l <br /> Business Rep Title O /� O AM 2 0 AM <br /> v 0P J V 0P <br /> - - Operational Status Tire Type Business Role Storage Type <br /> Tire Count (Whole/PTE) v-7 (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> I <br /> 0 Active Passenger 1@1 Generator • Outdoor <br /> o Q Closed ® Altered <br /> GPS Latitude Q Hauler Q Indoor <br /> O Q Inactive Truck <br /> Longitude - Q Planned OTR ® 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 I® Agriculture Q Shredder Q 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 /> 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 /> Q Q PRC§42956-Registration/Decal in Vehicle <br /> Q Q 14 CCR§18459-Responsible Entities Complying with Manifesting Requirements Date <br /> 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 EXTJ N <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 /> 2 <br /> Q Q 14 CCR§18461 -Manifest System Requirements for Waste Tire End-Use Facilities w <br /> Q Q 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators = <br /> In Compliance-No Violations o <br /> Q Q1 Other:§ <br /> Comments ' <br /> I— <br /> I 41nSMLA <br /> I <br /> Inspection Form�nc <br /> ncluded: )/)1,// A" <br /> Comments luded: ® - - -- <br /> Business ep's Signa ure 7Vh6ne Number Inspectos Signature hone Number <br /> INSTRUCTIONS ON BACK Correct:I, Incorrect: IE X A P 1 213 62081 <br /> ■ White Copy:CalRecycle Yellow Copy:Operator Pink C py: ® ■ <br />