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Waste Tire #Jrvey + Mspecfien h1spo"Inspection Report Number <br /> CalRecycle State of California 0 ■ <br /> CalRecycle 181(Rev.10/10) S p g rte` � Q Form <br /> o1I It I!� f� / `a /� <br /> Dept.of Resources Recycling and Recovery(CalRecycle) V h tl 'J ff I� l 3 Page 1 Ij `$ 2 J `f <br /> Part A-Survey BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- inspection Inspection Type(Fill one) <br /> Site Suffix: SRoutine QRe-ins Re-inspection <br /> Q Referral Q Observation <br /> Local / If Referral,choose referral type(Fill one) <br /> Identifier: Sin J p( Gjr l(�1A�1 Q CHP Q CalRecycle0 Complaint Q Educational Visit Q Other <br /> Business or Facility Name 1 l Inspected By Inspector <br /> *Lm \pI Urc�,X01 n [n 31 <br /> - i 0 <br /> Physical Address J l ` , -S to^[-o <br /> 5A o A�O C �Z I Inspection Date <br /> Time In ( Time Out <br /> Business Rep Title Q AM Q AM <br /> (7—,..p <br /> ' �ur,u <br /> 0 U Q PM � 3 U 0 PM�n S�Ii S QS <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 /> ® Active Q Passenger ® Generator Q Outdoor <br /> O Q Closed Q Altered 11 v <br /> G�� Latitude Hauler Q Indd- <br /> Q <br /> O Q Inactive ® Truck <br /> Longitude - <br /> 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 ® Other <br /> t, <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§184592.1 -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 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 u, <br /> Q Q 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators <br /> Q Q Other:§ O&ln Compliance-No Violations o <br /> Comments ref, L,,JL `C7 4NS C1ci-4 - - - <br /> �Ar�w <br /> y kll "-" OJ U Tugs 67 �cern- <br /> Inspection Form Included: ( l <br /> Comments Included: ®Q -2 <br /> ure Phone Number Insp or's Signature hone Number <br /> INSTRUCTIONS ON BACK Correct:0 Incorrect: E X A M P L E 11 2131 62081 <br /> ■ White Copy:CalRecycle Yellow Copy:Operator Pink Copy:L ■ <br />