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02 Waste Tire Su. ✓ey & Inspection Report Inspection Report Number <br /> cle State of California <br /> CalRecycle CalRecycle 181(Rev.10/10) 11 Form - Page 1 I1 1210202 <br /> Recycle) <br /> Dept.of Resources Recycling and Recovery(CalRecycle) Survey <br /> Part A-Survey BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- 1 G1 tj _71 _ O Inspection Type(Fill one) <br /> Site Suffix: - * Routine Q Re-inspection Q Referral Q Observation <br /> Local co If Referral,choose referral type(Fill one) <br /> Identifier: V� V'A Q CHP Q CalRecycle Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name Inspected By Inspector <br /> Physical Address <br /> CX- q,S3����- <br /> Inspection Date / 0 <br /> J <br /> Time In Time Out <br /> Business Rep Title 1 C 0 AM 0 AM <br /> 9 PM ®PM <br /> C�Lv&I C' Operational� �2 O�CC-� <br /> Operational Status Tire Type Business Role Storage Type <br /> Tire Count(Whole/PTE) <br /> c) (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> IR Active Q Passenger O Generator Q Outdoor <br /> Q Closed Q Altered <br /> GPS Latitude Q Hauler S Indoor <br /> O Q Inactive 0 Truck <br /> Longitude _ Q Planned 0 OTR Q End-Use Q Container <br /> Business Type(Fill all that apply) FIWIA <br /> Q New Tire Dealer Q Auto Repair 0 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 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 /> Q Q 14 CCR§18459-Responsible Entities Complying with Manifesting Requirements Date <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 EXTJ N <br /> a <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 /> 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 in Compliance-No Violations o <br /> Q 1 Q 1 Other:§ <br /> Comments by �2 vswS�_ Vc-4- \v` ly\P— OV\ -NAe\'-S Ad'k N <br /> 0.", � `�'" \mac,C V�.a <br /> (' ec-h <br /> Inspection Form Included: O 2 <br /> Comments Included: _ d � <br /> Business Rep' Sig ture Phone Number Inspe tor's Signature Phone Number . <br /> INSTRUCTIONS ON BACK Correct: Incorrect: X J� qfjjEjXjAjMjPjLjEj 111213620811 <br /> White Copy:CalRecycle Yellow Copy:Operator Pink Copy:LEA <br />