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Waste Tire Survey & Inspection Report Inspection Report Number <br /> State of California <br /> CalRecycle CalRecycle 181(Rev.10/10) 1244921 <br /> Dept.of Resources Recycling and Recovery(CalRecycle) Survey Form - Page 1 <br /> Part A-Survey BLUE OR BLACK INK PEN , <br /> Business Profile Inspection Details <br /> TPID- 0 inspection Type(Fill one) <br /> Site Suffix: 9 Routine 0 Re-inspection 0 Referral 0 Observation <br /> Local 1 If Referral,choose referral type(Fill one) <br /> Identifier: so1<61A., IA?n 0 CHP 0 CalRecycle 0 Complaint 0 Educational Visit 0 Other <br /> 9 — <br /> Business or Facility Nam Inspected By Inspector <br /> (ib�,() WIti3I <br /> Physical Address 0 co-FT <br /> '�317 Inspection Date <br /> Time In Time Out <br /> Business Rep Title A AM 0 AM <br /> 0 PM r d. b 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) <br /> Tire Count(Whole/PTE) 3 41,Active 40 Passenger 0 Generator 0 Outdoor <br /> GPS Latitude 0 0 Closed 0 Altered 0 Hauler ® Indoor <br /> 0 0 Inactive 0 Truck <br /> Longitude 0 Planned 0 OTR 0 End-use 0 Container <br /> Business Type(Fill ail that apply) <br /> 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 <br /> Part B- Inspection of Waste Tire Dealer, Generator, Hauler and End-Use Facility ENFORCEMENT STATUS <br /> V I A I 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 /> 00 14 CCR§18459-Responsible Entities Complying with Manifesting Requirements Date m <br /> / 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 EXT) N <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 /> 2 <br /> LU <br /> 0 0 14 CCR§18461 -Manifest System Requirements for Waste Tire End-Use Facilities <br /> 0 0 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators <br /> in Compliance-No Violations <br /> 0 0 Other:§ <br /> Comments <br /> NO 0110LA'In& 63 <br /> Inspection Form Included: 0 ( 07 <br /> Comments Included: eoax"4L <br /> Business Rep's Signature Phone Number :�Inkspjeo7r'sSignature Phone Number <br /> 62081 <br /> INSTRUCTIONS ON BACK [Correct Incorrect: EXAM Pf L 1 2 3 <br /> White Copy:CalRecycle Yellow Copy:Operator Pink Copy: <br />