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2 Waste Tire ey & Inspection Reporf inspection Report Number <br /> CalRecycle State of California T <br /> CalRecycle 181(Rev.10/10) Surve3 1 <br /> Dept of Resources Recycling and Recovery(CalRecycle) Survey Form - Page 1 <br /> Part A-Survey - BLUE OR BLACK INK PEN_ <br /> Business Profile Inspection Details <br /> TPID- h �f� 1 Inspection Type(Fill one) <br /> Site Suffix: 1 `1 (D Q V l ® Routine Q Re-inspection Q Referral Q Observation <br /> Local r� If Referral,choose referral type(Fill one) <br /> Identifier: q 1 C 0(�(�� Q CHP Q CalRecycle Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name �1 Inspectaed By- I <br /> Inspector <br /> Q, 6X 'T oPhysical Addre G � <br /> 3 <br /> ti- "-r- W q <br /> Inspection Date <br /> S � 69 O A a5 a�lv «l I <br /> Time In Time Out <br /> Business Rep TitleQ O AM O AM <br /> PM O PM <br /> \s I Cn -- Q W o6 Operational Status Tire Type Business Role Storage Type <br /> Tire Count (Whole/PTE) S 71 (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> ' (�/ ® Active 0 Passenger * Generator ® Outdoor <br /> 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 /> ® Used Tire Dealer Q Auto Body Q Car Dealer Q Collection Q Crumb Rubber <br /> Q Service Station Q Hauler Q 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 PRC§42951 -Waste Tire Hauler Registration and Transport of Tires <br /> Q PRC§42953-Contracts with Registered Waste Tire Haulers. Compliance Deadline <br /> Q Q PRC§42956-Registration/Decal in Vehicle <br /> QQ 14 CCR§18459-Responsible Entities Complying with Manifesting Requirements Date <br /> M / M / Ffl <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 EXE N <br /> Q ® 14 CCR§18459.3-Retention of Comprehensive Trip Logs for 3 years <br /> Q Q 14 CCR§18460.2-Manifest System Requirements for Registered Waste Tire Haulers Q Referred/CalRecycle Enforcement <br /> L <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 in Compliance-No Violations o <br /> Q Q Other:§ <br /> z <br /> Comments �b !r no, G4 , 1 j`t nc'o J 00AI,S A e. <br /> - <br /> - <br /> Inspection Form Included: Q <br /> Comments Included: ® <br /> Business Rep' ign ure \ Pho a Number lnsp�r,Ilgntur, Phone Number <br /> INSTRUCTIONS ON BACKCorrect:0 Incorrect: XZ � EXAMPLE 1 2 3 62081 <br /> ■ White Copy:CalRecycle Yellow Copy:Operator Pink Copy:LEA ® ■ <br />