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Waste Tire Sur vey & Inspection Report Inspection Report Number ■ <br /> CalRecycle State of <br /> CalRecycle1ifornia 181(Rev.10/10) Survey Form - Page 1 11 v 1177818 <br /> Dept.of Resources Recycling and Recovery(CalRecycle) <br /> Part A-Survey BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- e, - Q Inspection Type(Fill one) <br /> Site Suffix: 0 Routine 0 Re-inspection 0 Referral 0 Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier: Sao \TOUTAU� (0�-4j� _ 0 CNP 0 CalRecycle 0 Complaint 0 Educational Visit 0 Other <br /> Business or Facility Name I Inspected By Inspector <br /> �L <br /> y � �P 3 - 0 <br /> Physical Address <br /> 4-' Co'� C , Fr e room _ - - - - <br /> ��� � Inspection Date a / <br /> Time In Time Out <br /> Business Rep Title 1 GC) O AM O AM <br /> \ t l ® PM ® PM <br /> V q iii lti lk'v � 11�no (34k,Ic <br /> Operational 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 /> 0 Active # Passenger 0 Generator 0 Outdoor <br /> O 0 Closed 0 Altered W A <br /> GPS Latitude • Hauler 0 Indoor <br /> O 0 Inactive ® Truck <br /> Longitude - 0 Planned 0 OTR 0 End-Use 0 Container <br /> Business Type(Fill all that apply) <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 ® 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 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 /> PRC§42956-Registration/Decal in Vehicle <br /> 0 0 14 CCR§18459-Responsible Entities Complying with Manifesting Requirements Date m / m / m a <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/ <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 /> 2 <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 L 0 Other:§ __- <br /> _I <br /> Comments \ �'� Ti I c, 1�r S f�,�'1(� 118a _a Gt, e. iAmeA7 <br /> M1- <br /> Inspection Form Included: 0 <br /> Comments Included: "t D�f <br /> 71 <br /> in- g e Phone Number Insp or's Signature Phone Number <br /> INSTRUCTIONS ON BACK FCorrect:l• Incorrect: jEjXjA5'j'MjPjLjEj 1112 3 62081 <br /> ■ White Copy:CalRecycle Yellow Copy:Operator Pink Copy:LEA ® ■ <br />