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Waste Tire Su, dey & Inspection Repori nspection Report Number <br /> State of California <br /> CalRecycle <br /> CalRecycle 181(Rev.10/10) Survey Form - Page 1 I1 - 1226577 <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: r� Ll �, l ® Routine Q Re-inspection Q Referral Q Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier: sc�_V\ � �� �w� Q CHP Q CalRecycle Q Complaint Q Educational Visit Q Other <br /> Business orFacility Name \ Inspected By Inspector <br /> > <br /> C, \a&e, <br /> Physical Address <br /> am }� 1 Inspection Date 0 <br /> sy`vcl� ' " ' \` �" 4 Time In Time Outy <br /> Business Rep <br /> Title AM AM <br /> j1 <br /> -({J 0 QPM ` ( OPM elf l� �vrl�, � - - -- <br /> Operational Status Tire Type Business Role Storage Type <br /> Tire Count (Whole/PTE) <br /> (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> '1 ® Active ® Passenger ® Generator ® Outdoor <br /> O Q Closed Q Altered <br /> GFS Latitude Q Hauler ® Indoor <br /> 0 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 I* 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 Q - Q Notice Of Violation Q Extension <br /> § <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 FU / FP / m <br /> Q Q 14 CCR§18459.1 -Tire Program ID Number from CalRecycle a <br /> Q Q 14 CCR§18459.2.1 -Submittal of Comprehensive Trip Logs within 90 days (Required for NOV or EXT) N <br /> a <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 /> } <br /> W <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 In Compliance-No Violations o <br /> Q Q Other:§ <br /> Comments <br /> Inspection Form Included: Q <br /> Comments Included: <br /> a�-ti Zog y�5- LLo7 -46 - <br /> Business Rep's Signature Phone Number s ctor s Ig ture Phone Number <br /> INSTRUCTIONS ON BACK Correct:0 Incorrect: E X A Mj?qLl 111213 62081 <br /> ■ White Copy:CalRecycle Yellow Copy:Operator Pink Copy: ® 0 <br />