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Waste Tire Survey & Inspection Report Inspection Report Number <br /> CalRecycle State of Ca 1081(a 11 - 1210482 <br /> CalRecycle 181(Rev.10/10) Survey Form - Page 1 <br /> Dept.of Resources Recycling and Recovery(CalRecycle) BLUE OR BLACK INK PEN <br /> Part A-Survey - - <br /> Business Profile Inspection Details <br /> TPID- `` �^ Q (� Inspection Type(Fill one) <br /> Site Suffix: 1 J 1 5 "l O l 0 Routine 0 Re-inspection 0 Referral 0 Observation <br /> Locals I If Referral,choose referral type(Fill one) <br /> Identifier: Solm J O 0_ VAI f1 Cou 0 CHP 0 CalRecycle 0 Complaint 0 Educational Visit 0 Other <br /> Business or Facility Name Inspected By Inspector <br /> �u se �P�esS �t uv�'Li F) to <br /> 3 - U Esv-a <br /> Physical Address 1� <br /> Inspection Date <br /> 7 �� P <br /> r\ �� S�3 InsTime In Time Out <br /> Business Rep Title 0 AM eC0 AM <br /> S S PM J O 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) I <br /> ® Active ® Passenger ® Generator 0 Outdoor <br /> 0 0 Closed 0 Altered <br /> GPS Latitude 0 Hauler • Indoor <br /> 0 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 40 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 U4 e. <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 a <br /> (Required for NOV or EX7) <br /> 0 0 N <br /> 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 o <br /> 0 0 14 CCR§18460.2-Manifest System Requirements for Registered Waste Tire Haulers 0 Referred/CalRecycle Enforcement <br /> W <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 o <br /> 0 0 Other:§ <br /> Comments <br /> N of <br /> Inspection Form Included: 0*Businessls <br /> a�)lob•I�4 � t, <br /> 14 <br /> Comments Included: <br /> ure Phone Number Insp tor's Signature hone Number <br /> 62081 <br /> INSTRUCTIONS ON : Incorrect: I E X A P L E 111273 <br /> ■ White Copy:CalRecycle Yellow Copy:Operator Pink Co y:L ® ■ <br />