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Waste Tire jurvey & Inspection Report Inspection Report Number <br /> State of California <br /> CalRecycle — <br /> CalRecycle 181(Rev.10/10) Survey Form - Page 1 I1 1245192 <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/0 Inspection Type(Fill one) <br /> Site Suffix: I z/ (J 1* Routine 0 Re-inspection 0 Referral 0 Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier: L (,'L"'l_ 0 CHP 0 CalRecycle 0 Complaint 0 Educational Visit 0 Other <br /> Business or Facility Name <br /> 'w �� • ,, Inspected By Inspector <br /> Physical Address /, J l C�IJ/►'1✓�'� I"'� <br /> 2 Soh o Ne.. c�. <br /> 7)-nCc� ^A— 9S-377 <br /> ! l / _Z` I j <br /> uC' J Time In Time Out <br /> Business Rep Tale 0 AM <br /> 1 � `{ � ® PM ' _5 � � PM <br /> C j`1 UC t-C�up:5a n `n . l�k[t�fa <br /> perational 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 0 Passenger ® Generator 0 Outdoor <br /> O 0 Closed 0 Altered /tl�k_ <br /> GPS Latitude 0 Hauler 0 Indoor <br /> O 0 Inactive 0 Truck <br /> Longitude - 0 Planned • OTR 0 End-Use 0 Container <br /> Business Type(Fill all that apply) (((,u <br /> 0 New Tire Dealer 0 Auto Repair 0 Trucking Fleet 0 Government 0 Retreader 0 Dismantler 0 Tire Derived Fuel <br /> 0 Used Tire Dealer 0 Auto Body 0 Car Dealer 0 Collection 0 Crumb Rubber <br /> 0 Service Station 0 Hauler 0 Agriculture 0 Shredder 0 Other Vi <br /> Part B - Inspection of Waste Tire Dealer, Generator, Hauler and End-Use Facility ENFORCEMENT STATUS <br /> V A HAULING AND MANIFEST REQUIREMENTS <br /> 0 0 PR0 Notice Of Violation 0 Extension <br /> C§ -42951 Waste Tire Hauler Registration and Transport of Tires <br /> 0 0 PRC§42953-Contracts with Registered Waste Tire Haulers. Compliance Deadline <br /> PRC§42956-Registration/Decal in Vehicle <br /> 0 0 14 CCR§18459-Responsible Entities Complying with Manifesting Requirements Date m / m / m <br /> 0 0 14 CCR§18459.1 -Tire Program ID Number from CalRecycle <br /> 0 0 14 CCR§18459.2.1 -Submittal of Comprehensive Trip Logs within 90 days (Required for NOV or EXE n <br /> 0 0 14 CCR§18459.3-Retention of Comprehensive Trip Logs for 3 years <br /> 0 <br /> 0 0 14 CCR§18460.2-Manifest System Requirements for Registered Waste Tire Haulers 0 Referred/CalRecycle Enforcement <br /> 0 0 14 CCR§18461 -Manifest System Requirements for Waste Tire End-Use Facilities W <br /> 0 0 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators <br /> In Compliance-No Violations o <br /> 0 1 0 1Other:§ <br /> Commentskid <br /> t <br /> � Q7 <br /> too 12 <br /> Inspection Form Included: 0 <br /> Comments Included: 0 <br /> LZ� A, -- Zin 4&k- <br /> Business Rep' ignature Phone Number Inspector's Signature Phone Number <br /> +z <br /> INSTRUCTIONS ON BACK Incorrect: E X A M P L E 1 2 3 62081 <br /> orrect: <br /> ■ White Copy:CalRecycle Yellow Copy:Operator Pink Copy:LEA © ■ <br />