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Waste Tire Sive vey & Inspection Report Inspection Report Number ■ <br /> State of California <br /> CalRecycle CalRecycle 181(Rev.10/10) 11 - 1230358 <br /> De.pt.of Resources Recycling and R.ecovery(CalRecycle) Survey Form - Page 1 <br /> Part A-g�urvey BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- 13 Inspection Type(Fill one) <br /> C L <br /> Site Suffix: 40 Routine 0 Re-inspection 0 Referral 0 Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier: 0 CHIP 0 CalRecycle 0 Complaint 0 Educational Visit 0 Other <br /> Business or Facility Name u Inspected By Inspector <br /> Physical Ad <br /> , s <br /> t-7 6 dcyv� OF"> 6� Ave-, <br /> Inspection Date C1 <br /> A q5;4p��> Time In Time Out <br /> Business Rep Title 0 AM 0 AM <br /> z�,r+Q-ez— Co-C)LAANkV- a PM ® PM <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 40 Passenger a Generator 40 Outdoor <br /> GpS Latitude 0 0 Closed 0 Altered 0 Hauler 0 indoor <br /> 0 0 Inactive 0 Truck <br /> Longitude 0 Planned 0 OTR 0 End-Use 0 Container <br /> Business Type(Fill all that apply) <br /> Q 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 A HAULING AND MANIFEST REQUIREMENTS 6P 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 <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 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 /> X <br /> 0 0 14 CCR§18461 -Manifest System Requirements for Waste Tire End-Use Facilities Lu <br /> 0 0 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators 0 In Compliance-No Violations <br /> 0 0 Other:§ <br /> Comments A <br /> SP C4041 01 C-4nA-> Vit V <br /> Inspection Form Included: 0 <br /> -e <br /> Comments Included. <br /> Business Rep's S. Phone Number I P i6ragnoiure Phone Number <br /> 7V �� <br /> INSTRUCTIONS ON BACK Correct:* incorrect: q E A 262081 <br /> White Copy:CalRecycle Yellow Copy:Operator Pink Cop L ■ <br />