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Waste Tire <br /> Sule & Inspection Reportort inspection Report Number <br /> State of California <br /> CalRecycle 181(Rev.10/10) <br /> Survey Form - Page 1 1 - 1177864 <br /> Dept.of Resources Recycling and Recovery(CalRecycle) <br /> Part A-Survey_- BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- 6 O r Inspection Type(Fill one) <br /> Site Suffix: 15 6 ALJ ` ® Routine Q Re-inspection Q Referral Q Observation <br /> Local1 l If Referral,choose referral type(Fill one) <br /> Identifier: S(4,0 —jQ u tAl O CHP Q CalRecycle Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name Inspected By Inspector <br /> T <br /> Physical Address I LS <br /> 3�o 0\ <br /> � �j GA qSu Inspection Date 1 0 "1 i 3 <br /> b v�b r J Time In Time Out <br /> Business Rep Title ' 0 I 5PM AM ( l O U 0 PM <br /> I I <br /> AM <br /> r w ��u n Vii 1 �bl% MIu \ <br /> Operational Status Tire Type Business Role Storage Type <br /> Tire Count(Whole/PTE) r C' O (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> 0 Active ® Passenger 0 Generator 0 Outdoor <br /> O Q Closed O Altered <br /> GPS Latitude Q Hauler 0 Indoor <br /> O Q Inactive Q Truck <br /> Longitude - Q Planned O OTR 0 End-Use O Container <br /> Business Type(Fill all that apply) <br /> 0 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 O 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 /> 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 O 14 CCR§18459-Responsible Entities Complying with Manifesting Requirements Date m / m / m N <br /> 0. _ 14 CCR§18459.1 -Tire Program ID Number from CalRecycle <br /> O O 14 CCR§18459.2.1 -Submittal of Comprehensive Trip Logs within 90 days (Required for NOV or EXE N <br /> Q 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 /> W <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 S rn Compliance-No Violations o <br /> O O Other:§ <br /> Comments 2� +il u on f (AvdN <br /> U)'M � 'no <br /> Sem CUA For", <br /> Inspection Form Included: Q -,, <br /> Comments Included: <br /> Busin Reps Signature PhoneNumber h.por's Signature Phone Number <br /> 62081 <br /> INSTRUCTIONS ON BACK Correct: Incorrect: IEIXIAIMIPAJEJ 1 2 3 <br /> White Copy:CalRecycle Yellow Copy:Operator Pink Copy:V <br />