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Waste Tire Sui Bey & Inspection Report Inspection Report Number ■ <br /> CalRecycle state of calffornia <br /> CalRecycle 181(Rev.10110) <br /> Survey Form - Page 1 11 - 1178019 <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 Inspection Type(Fill one) <br /> Site Suffix: 4b Routine Q Re-inspection Q Referral Q Observation <br /> LocalC�Un� If Referral,choose referral type(Fill one) <br /> Identifier: 5AI) lA; n Q CHP Q CalRecycle Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name <br /> Inspected By Inspector <br /> V ee.? 0n �QLLc,\Cr� _ ' 0 <br /> Physical Address C-I/ 0 <br /> CA sZ�3 <br /> Inspection Date <br /> � <br /> Time In Time Out <br /> Business Rep I Title O AM 1Q AM <br /> l��},�I 0 PM O is PM <br /> f1 c, IIfrhln� � �. <br /> Operational Status Tire Type Business Role Storage Type <br /> Tire Count (Whole/PTE) -3 (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> 40 Active Q Passenger 0 Generator 0 Outdoor <br /> GPS Latitude 0 Closed Q Altered <br /> Q Hauler ® Indoor <br /> O Q inactive 0 Truck <br /> Longitude - Q Planned Q OTR Q End-Use 0 Container <br /> Business Type(Fill all that apply) <br /> Q New Tire Dealer Q Auto Repair 0 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 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 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 m / m / m <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 Ex7) 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 /> 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 /> Comments � ot.(9 <br /> V <br /> No v�ola�ic�ts us voftt; 4 egr1(d( <br /> Inspection Form Included: Q <br /> aR o 0149_ <br /> Comments Included: ® � -�ig.at.rq <br /> _6601) <br /> Bu ness Rep's Signature Phone Number Inspe 11hone Nu <br /> mber <br /> INSTRUCTIONS ON BACK Correct:0 Incorrect: E X A L 11213 62081 <br /> ® � <br /> ■ White Copy:CalRecycle Yellow Copy:Operator Pink Cop :L ® ■ <br />