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Waste TISSe & Inspection Repo Report Number <br /> CalRecycle y P _ <br /> State of California <br /> Y CalRecycle 181(Rev.10/10) Survey Form - Page 1 1 1255744 <br /> Dept.of Resources Recycling and Recovery(CalRecycle) <br /> part A- Survey BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- /,, �j Inspection Type(Fill one) <br /> Site Suffix: 2- (y [ r 0 Routine Q Re-inspection Q Referral Q Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier: �Tyjr,V O CHP O CalRecycle Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name Inspected By Inspector <br /> Coyyyan) <br /> Physical Address <br /> t�� ice ►-trL 2cLt <br /> --11-330 <br /> Inspection Date ! I 1 Z_ l 5 <br /> Time In Time Out <br /> Business Rep Title O AM O AM <br /> ICo-£lJ, FGcl _ ® PM Z ' 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 /> V &Active a Passenger Generator O Out or <br /> O Q Closed O Altered <br /> NP— <br /> GpS Latitude Q Hauler Q Indoor <br /> 0 0 Inactive Q Truck <br /> Longitude – Q Planned ® OTR O 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 O 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 O Agriculture Q Shredder ® Other ok-I bt_) `)II n P j6 <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 /> O O <br /> PRC§42951 -Waste Tire Hauler Registration and Transport of Tires <br /> O O PRC§42953-Contracts with Registered Waste Tire Haulers. Compliance Deadline <br /> O O PRC§42956-Registration/Decal in Vehicle <br /> O 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 0 14 CCR§18459.2.1 -Submittal of Comprehensive Trip Logs within 90 days (Required for NOV or EXE N <br /> O O 14 CCR§18459.3-Retention of Comprehensive Trip Logs for 3 years o <br /> O O 14 CCR§18460.2-Manifest System Requirements for Registered Waste Tire Haulers Q Referred/CalRecycle Enforcement <br /> 2 <br /> w <br /> O O 14 CCR§18461 -Manifest System Requirements for Waste Tire End-Use Facilities <br /> O O 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators ®In Compliance-No Violations o <br /> O O Other:§ <br /> CommentsWD1.4b,K__Q_ W t�i .� fse l�Jc.c_.--C/L_ ` /V L <br /> U1,0/cz.^cam 6-,- at.0_aa;- 01c__Crbr .t <br /> Inspection Form Included: Q <br /> Comments Included. �– <br /> Business Rep's Signature Phone Number Inspector's Signature Phone Number <br /> INSTRUCTIONS ON BACK Correct:* Incorrect: EXAMPLE 1 2 3 62081 <br /> ■ White Copy:CalRecycle Yellow Copy:Operator Pink Copy:LEA �� ■ <br />