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Waste Tire Su,vey & Inspection Report nspection Report Number <br /> CalRecycle State of California <br /> CalRecycle 181(Rev.10/10) purvey Form - Page 1 I1 - 1178023 <br /> Dept.of Resources Recycling and Recovery(CalRecycle) <br /> BLUE OR BLACK INK PEN <br /> Part A-Survey <br /> Business Profile Inspection Details <br /> TPID- I 1 1 r-� Q c - O Inspection Type(Fill one) <br /> Site Suffix: l� I J Routine Q Re-inspection Q Referral Q Observation <br /> Local �l ) If Referral,choose referral type(Fill one) <br /> Identifier: Sail �J O tAl/\ (,OU() Q CHP Q CalRecycle Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name Inspected By Inspector <br /> Physical Addre I CStoa <br /> 5331, Inspection Date / 0 S 1 <br /> Time In Time Out <br /> Business Rep Title O AM O AM <br /> . � U � PM � � 5 40 PM <br /> ''►a r un cLt S�u F01 u� <br /> Operational Status Tire Type Business Role Storage Type <br /> (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> Tire Count (Whole/PTE) Q 5 <br /> • Active ® Passenger ® Generator Q Outdoor <br /> O Q Closed Q Altered <br /> GPS Latitude Q Hauler Q Indoor <br /> O Q Inactive 0 Truck <br /> Longitude - Q Planned ® OTR Q End-Use • 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 ® 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 /> QQ 14 CCR§18459-Responsible Entities Complying with Manifesting Requirements Date M / Ffl / <br /> m <br /> Q Q 14 CCR§18459.1 -Tire Program ID Number from CalRecycle N <br /> Q Q 14 CCR§18459.2.1 -Submittal of Comprehensive Trip Logs within 90 days (Required for NOV or EXT) <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 e In Compliance-No Violations o <br /> Q Q Other:§ z <br /> Comments , I <br /> S Pe, rIn <br /> �cb eA<Ifl ' <br /> Inspection Form Included: O <br /> 609-g � q�41��-3►� <br /> Comments Included: <br /> Business Revs Signature Phone Number Inspe t is Signature Phone Number <br /> INSTRUCTIONS ON BACK Correct:10 Incorrect: g EXAM E 2 3 62081 <br /> ■ White Copy:CalRecycle Yellow Copy:Operator Pink Co : ® I <br />