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Waste Tire Survey & Inspection Report Inspection Report Number M <br /> State of California <br /> CalRecycle CalRecycle 181(Rev.10/10) 11 - 1210569 <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- Inspection Type(Fill one) <br /> Site Suffix: d- /0 LT J 1 0 Routine 0 Re-inspection 0 Referral 0 Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier: C—V 0 CHP 0 CalRecycle 0 Complaint 0 Educational Visit 0 Other <br /> Business or Facility Name Inspected By Inspector <br /> Physical Address -3 q © <br /> qInspection Date L <br /> Time In Time Out <br /> Business Rep Title 0 AM (ib AM <br /> [ [ L QPM 1 QPM <br /> Hca L C) <br /> Operational Status Tire Type Business Role Storage Type <br /> Tire Count (Whole/PTE) 4— (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> -5 0 Active 0 Passenger 0 Generator *Outdoor <br /> GpS Latitude 0 0 Closed 0 Altered 0 Hauler ® Indoor <br /> 0 0 Inactive 0 Truck <br /> Longitude 0 PlannedA0 End-use 0 container <br /> M J <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 0 Hauler 0 Agriculture 0 Shredder Other Z 4+ CU2ej <br /> Part B- Inspection of Waste Tire Dealer, Generator, Hauler and End-Use Facility ENFORCEMENT STATUS <br /> V 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 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 EXT) <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 Other:§ <br /> Comments <br /> Inspection Form Included: 0 <br /> �AAq^ <br /> Comments Included: 411 <br /> Busi ss ep's Signature vPhone Number Vj/potorfsi ature Phone Number <br /> INSTRUCTIONS ON BACK �Correct:e incorrect: X � VIEXAMP JEJ 1112 3 <br /> 62081 <br /> MWhite Copy:CalRecycle Yellow Copy:Operator Pink&y. FA M <br />