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Waste Tire S.__ ✓ey & Inspection Repor,. ,Inspection Report Number ■ <br /> State of California <br /> CalRecycle I 1 - 1210275 <br /> CalRecycle 181(Rev.10/10) <br /> (Cal Survey Form - Page 1 <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 Q I! Routine Q Re-inspection Q Referral Q Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier: S omi u 14 Q CHP Q CalRecycle Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name y� <br /> 11 I Inspected By Inspector <br /> iWY l ` <br /> Physical A dress <br /> 64� Bq <br /> w /��v� Inspection Date <br /> vfl� Time In Time Out GJ <br /> Business Rep Title J b 0 AM �J Q AM <br /> `J OPPM (i D a PM <br /> Operational Status Tire Type Business Role Storage Type <br /> Tire Count (Whole/PTE) d (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> �j lb Active 0 Passenger 0 Generator Q Outdoor <br /> O Q Closed Q Altered <br /> GPS Latitude Q Hauler Q Indoor <br /> o Q Inactive *Truck <br /> LongitudeQ- Planned Q OTR Q End-Use 4Vontainer <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 `Collection Q Crumb Rubber 9 <br /> Q Service Station Q Hauler Q Agriculture Q Shredder 4$ 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 N <br /> Q Q 14 CCR§18459.2.1 -Submittal of Comprehensive Trip Logs within 90 days (Required for NOV or EXTJ 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 Q In Compliance-No Violations o <br /> Q Q Other:§ <br /> Comments <br /> J.ate. '►Nd <br /> a vs s4h*4 S <br /> Inspection Form Included: Q Z-0 9 V7 <br /> Comments Included: Q- `3�6 <br /> usiness Rep's Signature Phone Number Inspector's Signature Phone Number <br /> INSTRUCTIONS ON BACK Correct:I• Incorrect: " g E X A M P L E 1 2 3 62081 <br /> ■ White Copy:CalRecycle Yellow Copy:Operator Pink Copy:LEA <br />