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■ <br /> Waste Tire Survey & Inspection Report Inspection Report Number <br /> State of California <br /> CalRecycle CalRecycle 181(Rev.10/10) Survey Form - Page 1 11 - 1226688 <br /> Dept.of Resources Recycling and Recovery(CalRecycle) BLUE OR BLACK INK PEN <br /> Part A-Surve f <br /> Business Profile Inspection Details <br /> TPID- Inspection Type(Fill one) <br /> Site Suffix: 5 0 Routine 0 Re-inspection 0 Referral 0 Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier: 0 CHP 0 CalRecycle 0 Complaint 0 Educational Visit 0 Other <br /> Business or Facility Name Inspected By Inspector <br /> [A , � E�-s <br /> Physical Address <br /> r <br /> Zc(to bo_"� Q -b Inspection Date <br /> cA 95 3 v Time In Time Out <br /> Title C) AM 0 AM <br /> Business Rep 0 PM0 PM <br /> J(>',V\V- � <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) 15, ® Active ® Passenger ® Generator ® Outdoor <br /> GPS Latitude 0 0 Closed 0 Altered 0 Hauler 0 Indoor <br /> G 0 0 inactive 0 Truck 0 End-use 0 container <br /> Longitude 0 Planned 0 OTR <br /> Business Type(Fill all that apply) <br /> 0 New Tire 15e-aler (o Auto Repair 0 Trucking Fleet 0 Government 0 Retreader 0 Dismantler 0 Tire Derived Fuel <br /> (jo 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 /> A HAULING AND MANIFEST REQUIREMENTS <br /> 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 FU <br /> 0 0 14 CCR§18459.1 -Tire Program ID Number from CalRecycle <br /> (Required for NOV or EXT) <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 /> 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 In Compliance-No Violations <br /> 0 0 1 Other:§ <br /> Comments <br /> Inspection Form Included: 0 3 91 'Y 6 7-Agg 3 <br /> comments Included: 10 siness R 's Signa Phone Number In or' Si6ture Phone Number <br /> 62081 <br /> INSTRUCTIONS ON BACK Correct:* incorrect: ® qq E X A <br /> -Ye A ® ■ <br /> ■ White Copy:CalRecycle Ilow Copy:operator Pink Co - <br />