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.0 <br /> 2 <br /> Waste Tire Survey & Inspection Report Inspection Report Number <br /> CalRecycle State of California - 1176584 <br /> CalRecycle 181(Rev.10/10) <br /> Dept.of Resources Recycling and Recovery(CalRecycle) BLUE <br /> Form - Page 1 BLUE OR BLACK INK PEN <br /> Part A-Survey - inspection Details <br /> Business Profile <br /> TPID- Inspection Type(Fill one) <br /> Site Suffix: L1 0 1 0 Routine 0 Re-inspection 0 Referral 0 Observation <br /> LocalCIf Referral,choose referral type(Fill one) <br /> Identifier: <br /> 0 CHP 0 CalRecycle 0 Complaint 0 Educational Visit 0 Other <br /> :lr� l <br /> ess�r Facility Inspector <br /> Business Inspected By <br /> Physical Address 17 Bew_�4,- <br /> Inspection Date 0 C, <br /> Time In Time Out <br /> Business Rep Title 0 AM c) 0 AM <br /> 0 PM C) PM <br /> IDA, i"a Cox -Assi'a'VA keir, 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 0 Passenger 9 Generator 0 Outdoor <br /> 0 0 Closed 0 Altered <br /> GPS Latitude 0 0 inactive ® Truck <br /> 0 Hauler 0 Indoor <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 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 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 <br /> 0 0 14 CCR§18459.1 -Tire Program ID Number from CalRecycle <br /> (Required for NOV or EXT) 6i <br /> 0 0 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 �R <br /> 0 0 14 CCR§18460.2-Manifest System Requirements for Registered Waste Tire Haulers 0 Referred CalRecycle Enforcement <br /> 2; <br /> Lu <br /> 0 0 14 COR§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 40 in compliance-No Violations <br /> 0 0 Other: <br /> Comments //c,L' <br /> ---------------- <br /> Inspection Form Included: 0 (1-2- -0-6 Z <br /> X <br /> Comments Included: <br /> included: Business Rep's Signature Phone Number Inspector's Signature Phone Number <br /> 62081 <br /> Correct:0 Incorrect: <br /> INSTRUCTIONS ON BACK zs� q <br /> NWhite Copy:CalRecycle Yellow Copy:operator PinkA <br />