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Waste Tire Su. vey & Inspection Report Inspection Report Number ■ <br /> State of California <br /> CalRecycle <br /> CalRecycle 181(Rev.10/10) Survey Form - Page 1 I1 - 1210509 <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: t "l S O I O Routine 0 Re-inspection I* Referral 0 Observation <br /> Local / y If Referral,choose referral type(Fill one) <br /> Identifier: &n__&tAjtA'n CD 1 n � 0 CHP # CalRecycle 0 Complaint 0 Educational Visit 0 Other <br /> Business or Facility Name Inspected By Inspector <br /> VIN-t <br /> Physical AQress 3 I 10 J cs cb-tr0 <br /> 112" L )�w I_ q9 <br /> 8f�On (A a�� Inspection Date <br /> q<- <br /> Time In �l Time Out <br /> Business Rep TitleS (� SAM l 0 AM <br /> 0 PM 1 a, I SPM <br /> Operational Status Tire Type Business Role Storage Type <br /> �y <br /> Tire Count(Whole/PTE) (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> �J <br /> 0 Active 0 Passenger 0 Generator 0 Outdoor <br /> O ® Closed 0 Alt l A ) <br /> GPS Latitude IA 0 Hauler I 0 Indoo <br /> O 0 Inactive 0 Truck <br /> Longitude - 0 Planned 0 OTR 0 End-Use 0 Container <br /> Business Type(Fill all that apply) <br /> 0 New Tire Dealer 0 Auto Repair 0 Trucking Fleet 0 Government ® Retreader 0 Dismantler 0 Tire Derived Fuel <br /> 0 Used Tire Dealer 0 Auto Body 0 Car Dealer 0 Collection 0 Crumb Rubber <br /> 0 Service Station 0 Hauler 0 Agriculture 0 Shredder 0 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 /> Notice Of Violation Q Extension <br /> 0 0 PRC§42951 -Waste Tire Hauler Registration and Transport of Tires <br /> 0 0 PRC§42953-Contracts with Registered Waste Tire Haulers. Compliance Deadline <br /> PRC§42956-Registration/Decal in Vehicle <br /> 0 0 14 CCR§18459-Responsible Entities Complying with Manifesting Requirements Date M / m / m <br /> 0 0 14 CCR§18459.1 -Tire Program ID Number from CalRecycle An <br /> 0 0 14 CCR§18459.2.1 -Submittal of Comprehensive Trip Logs within 90 days (Required for NOV or EXTJ N <br /> 0 0 14 CCR§18459.3-Retention of Comprehensive Trip Logs for 3 years o <br /> 0 0 14 CCR§18460.2-Manifest System Requirements for Registered Waste Tire Haulers 0 Referred/CalRecycle Enforcement <br /> 2 <br /> 0 0 14 CCR§18461 -Manifest System Requirements for Waste Tire End-Use Facilities W <br /> 0 0 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators <br /> In Compliance-No Violations o <br /> 0 0 Other:§ <br /> Comments01 r 0- (c1 l Gt �eutL e,,n f f I <br /> I < pI ant, 'q4 <br /> Inspection Form Included: 0 <br /> Comments Included: 0 117 <br /> Business Rep's Signature Phone Number In ector's Signature ` Phone Number <br /> INSTRUCTIONS ON BACK Correct:J9 Incorrect: ?Xg EXAM L 1 2 3 62081 <br /> ■ White Copy:CalRecycle Yellow Copy:Operator Pink Copy <br />