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Waste Tire Survey & Inspection Report Inspection Report Number <br /> State of California <br /> CalRecycle CalRecycle 181(Rev.10110) 11 - 1226321 <br /> Dept.of Resources Recycling and Recovery(CalRecycle) BLUE <br /> Form - Page 1 BLUE OR BLACK INK PEN <br /> Part A-Survey _ <br /> Business Profile inspection Details <br /> TPID- inspection Type(Fill one) <br /> Site Suffix: C) l 0 Routine 0 Re-inspection 0 Referral 0 Observation <br /> Local �"A If Referral,choose referral type(Fill one) <br /> Identifier: X <br /> 0 CHP 0 CalRecycle 0 Complaint 0 Educational Visit 0 Other <br /> -1 <br /> Business or Facility Name Inspected By Inspector <br /> Physical Address 9 _14, <br /> Inspection Date <br /> CA '?5I2M Time In Time Out <br /> Business Rep Title AM o*AM <br /> / C) : 0 0 0 PM _5 <br /> t — 0 PM <br /> Operational Status Tire Type Business Role Storage Type <br /> (Fill one only) (Fill all that apply) (Fill all that apply) Fill all that apply)1 <br /> Tire Count (Whole/PTE) 0 Active 0 Passenger Generator 40 Outdoor <br /> 0 0 Closed 0 Altered <br /> G PS Latitude Inactive 0 Truck Hauler 0 Indoor <br /> 0 0 Ina ID <br /> Longitude 0 Planned 0 OTR End-use 0 container <br /> Business Type(Fill all that apply) 0 Tire Derived Fuel <br /> I* New Tire Dealer 0 Auto Repair 0 Trucking Fleet 0 Government 0 Retreader 0 Dismantler <br /> Q? Used Tire Dealer 0 Auto Body 0 Car Dealer 0 Collection 0 crumb Rubber <br /> 0 Service Station 4D Hauler 0 Agriculture 0 Shredder 0 Other <br /> Part B- Inspection of Waste Tire Dealer, Generator, Hauler and End-Use Facility ENFORCEMENT STATUS <br /> IV A HAULING AND MANIFEST REQUIREMENTS 0 Notice of Violation 0 Extension <br /> 0 0 PRC§42951 -Waste Tire Hauler Registration and Transport of Tires <br /> 0 0 PRC§42953-Contracts with Registered Waste Tire Haulers. Compliance Deadline <br /> 0 0 PRC§42956-Registration/Decal in Vehicle <br /> 0 . 0 14 CCR§18459-Responsible Entities Complying with Manifesting Requirements Date M <br /> 0 0 14 CCR§18459.1 -Tire Program ID Number from CalRecycle <br /> (Required for NOV or EX7) <br /> 0 0 14 CCR§18459.2.1 -Submittal of Comprehensive Trip Logs within 90 days <br /> 0 0 14 CCR§18459.3-Retention of Comprehensive Trip Logs for 3 years <br /> 0 0 14 CCR§18460.2-Manifest System Requirements for Registered Waste Tire Haulers 0 Referred CalRecycle Enforcement <br /> Lu <br /> 0 0 14 CCR§18461 -Manifest System Requirements for Waste Tire End-Use Facilities <br /> 0 I 0 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators in compliance-No Violations <br /> 0 0 Other:§ <br /> 11 1 <br /> Comments <br /> 6111 <br /> Inspection Form Included: 0 a 9C.)— <br /> Comments Included: 0 Busi e ep's Signature Phone Number n is i ature Phone Number <br /> 62081 <br /> INSTRUCTIONS 014 BAG/K/ Correct:0 incorrect: E X A L 1_���21 31 <br /> ■ White Copy:CalRecycle Yellow Copy:operator Pink Ce y:: A <br />