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Waste Tire Survey & Inspection Report Inspection Report Number <br /> CalRecycle State of cleCalifornia81( T _ 1176362 <br /> � 1 7 6 3 6 2 <br /> CalRecycle 181(Rev.10/10) Survey Form - Page 1 _L ..L. I ..,� <br /> Dept.of Resources Recycling and Recovery(CalRecycle) <br /> BLUE OR BLACK INK PEN <br /> Part A-Survey <br /> Business Profile Inspection Details <br /> TPID- � � Inspection Type(Fill one) <br /> Site Suffix: ` • Routine 0 Re-inspection 0 Referral 0 Observation <br /> Local r-\-� If Referral,choose referral type(Fill one) <br /> Identifier: S�(� yUf ll��ln 60 t,(nd 0 CHP 0 CalRecycle 0 Complaint 0 Educational Visit 0 Other <br /> Business or Facility Name Inspected By Inspector <br /> Qual; &gt) ers 3 coy <br /> - C� 1 <br /> Physical Address_j <br /> 0 <br /> Inspection Date <br /> �1 Time In Time Out <br /> Business Re Title O AM O AM <br /> Rep 1 1 0 PM ` 5 ® PM <br /> - <br /> e o o l'i S S-�-Ar`►'LLua <br /> Operational Status Tire Type Business Role Storage Type <br /> Tire Count (Whole/PTE) /X (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> ® Active 0 Passenger • Generator 0 Outdoor <br /> � 0 Closed 0 Altered <br /> WA <br /> GPS Latitude 0 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 ® 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 I HAULING AND MANIFEST REQUIREMENTS <br /> 0 Notice Of Violation 0 Extension <br /> 0 0 <br /> 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 <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 EXE N <br /> n <br /> v <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 /> 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 10 In Compliance-No Violations o <br /> 0 0 Other:§ <br /> Comments ,1 ��).�y �S 1`5 �I� Gti N <br /> os <br /> Inspection Form Included: <br /> Comments Included: <br /> Busines ep's natu one Number Inspe or's Signat Phone Number <br /> INSTRUCTIONS ON BA K Correct:* Incorrect: V E X A E 1112131 <br /> 62081 <br /> ■ White Copy:CalRecycle Yellow Copy:Operator Pink Cop . ® ■ <br />