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02 Waste Tire ufte & Inspection Re spection Report Number <br /> CalRecycle y p p -1176485 <br /> State of California <br /> Y CalRecycle 181(Rev.10/10) Survey Form - Page 1 1 <br /> Dept.of Resources Recycling and Recovery(CalRecycle) <br /> Part A-SurveyBLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- � 1 Inspection Type(Fill one) <br /> Site Suffix: 0 0 Routine Q Re-inspection Q Referral Q Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier: n <br /> �� Q CHP Q CalRecycle Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name Inspected By Inspector <br /> `7� EIgjc,SS [_sjo <br /> Physical Address 31 _ I O ( &n <br /> Inspection Date / / I 1 <br /> CAq5x� Time In Time Out <br /> Business Rep Title O AM O AM <br /> I 0 0 PM O (� PM <br /> — -- — Operational Status Tire Type Business Role Storage Type <br /> Tire Count(Whole/PTE) (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> Q Active Q Pas en er Q Generator Q Outdoor <br /> O It <br /> Closed Q AN/A NA <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 /> 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 A Other COGSA-�j ori <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 Q Q Notice Of Violation Q Extension <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 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 EXT) n <br /> Q 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 /> Lu <br /> Q Q 14 CCR§18461 -Manifest System Requirements for Waste Tire End-Use Facilities <br /> Q Q 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators (9 In Compliance-No Violations o <br /> Q Q Other:§ � <br /> Comments &A61-- <br /> -k�� `CDJ� �S <br /> �l <br /> W1414 00ZA <br /> 0 or uc <br /> Inspection Form Included: Q ` <br /> 3Y78 <br /> Comments Included: <br /> Business Rep's_Signature Phone Number Insp tor's Signat re _ Phone Number <br /> 62081 <br /> INSTRUCTIONS ON BACK Correct:0 Incorrect: E X A E 1 2 3 <br /> ■ White Copy:CalRecycle Yellow Copy:Operator Pink Co y: © ■ <br />