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Waste Tire Survey & Inspection Report Inspection Report Number <br /> CalRec cle State of California _ <br /> Y CalRecycle 181(Rev.10/10) Survey Form - Page 1 I1 1242466 <br /> Dept.of Resources Recycling and Recovery(CalRecycle) <br /> Part A-Survey BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- Q �+� / _ Inspection Type(Fill one) <br /> Site Suffix: ` b (0 0 Routine 0 Re-inspection 0 Referral 0 Observation <br /> Local " � If Referral,choose referral type(Fill one) <br /> Identifier: tj J u 1�� 0 CHP 0 CalRecycle 0 Complaint 0 Educational Visit 0 Other <br /> Business or1Facility Name l _ Inspected By Inspector <br /> Physical Address 3 � <br /> 3R7 � �N . TORnrn'�c_ Ave ". <br /> � <br /> Inspection Date <br /> (u`�� � CA 9M'D Time In Time Out <br /> Business Rep TitleO O AM f,� 1 O 0 AM <br /> ® PM "l l e PM <br /> Operational Status Tire Type Business Role Storage Type <br /> Tire Count(Whole/PTE) 5 0 (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> Q Active 0 Passenger 4j Generator 48 Outdoor <br /> 0 Closed 0 Altered <br /> GPS Latitude 0 Hauler 0 Indoor <br /> 0 0 Inactive 0 Truck <br /> Longitude - 0 Planned (6 OTR 0 End-Use 0 Container <br /> Business Type(Fill all that apply) (ll') d' <br /> 0 New Tire Dealer ® 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 ml r C�dc acfA3J <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 Notice Of Violation 0 Extension <br /> 0 0 <br /> PRC§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 / <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 EX7) <br /> 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 In Compliance-No Violations o <br /> 0 0 Other::§ <br /> CommentsLJJti.skC +70- r2 1 � (2� �l U� (J1Q) , 1 (J� [ '`4 r� <br /> y�4 'T0 1171� <br /> s e2� (Chrn4t)j� <br /> Inspection Form Include 1 <br /> kG��317 <br /> Comments Included- <br /> siness Rep's Signature Phone Number Insp tor's Signature Phone Number <br /> 62081 <br /> INSTRUCTIONS ON BACKCorrect:0 Incorrect: EIXI I 1 2131 <br /> White Copy:CalRecycle Yellow Copy:Operator Pink Copy: <br />