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Waste Tire S ey & Inspection Repor- ispection Report Number ■ <br /> CalRecycle State of California <br /> CalRecycle 181(Rev.10/10) Survey Form - Page 1 11 - 1176559 <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: I 3 Z Lt 7 Z a ( e Routine Q Re-inspection Q Referral Q Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier: Q CHP Q CalRecycle Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name <br /> Inspected By Inspector <br /> l T /rurk,n _ <br /> �3Physical Address <br /> J I.3 q� Nf /4" `l <br /> Inspection Date <br /> Time In Time Out <br /> Business Rep Title 00 O AM r� Q AM <br /> ® PM PM <br /> - _ YlU�f �✓LcGI� -- �'12C�7f��GEvI9�I'f — <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 a Outdoor <br /> GPS Latitude Q Closed Q Altered <br /> Q Hauler ® Indoor <br /> O Q Inactive ® 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 ® 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 /> - _—. - .--.. - - -- - <br /> V A I HAULING AND MANIFEST REQUIREMENTS <br /> -- Q Notice Of Violation Q Extension i <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 N <br /> Q Q 14 CCR§18459.2.1 -Submittal of Comprehensive Trip Logs within 90 days (Required for NOV or EXE <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 /> 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 <br /> Q Q Other:§ <br /> Comments <br /> — ---��pyff_-r>2ci t`hC ,�G�`G�. 7�il��.UG-t-� -�YIL'✓� __ \ <br /> jN6i f I'ltJ.tr.�1: <br /> Inspection Form Included: Q X <br /> Comments Included: I* - - <br /> Bus s Rep's Si t re Phone Number I spector's Signature _Phone Number <br /> INSTRUCTIONS ON BACK 'Correct:0 Incorrect: N/ <br /> ]1ExF Fm FP JLJEJ 1112 3 62081 <br /> - - -- - <br /> White Copy:CalRecycle Yellow Copy:Operator Pink Copy:LEA <br />