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.... ....... <br /> A <br /> Waste Tire Survey & Inspection Report inspection Report Number <br /> CalRecycle State of California 11 - 12 2 6 6 8 6 <br /> CalRecycle 181(Rev.10/10) Survey Form - Page 1 <br /> Dept.of Resources Recycling and Recovery(CalRecycle) BLUE OR BLACK INK PEN <br /> PartA-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 CIf Referral,choose referral type(Fill one) <br /> Identifier: ���A 0 CHIP 0 CalRecycle 0 Complaint 0 Educational Visit 0 Other <br /> Business or Facility Name Inspected By Inspector <br /> Physical Address l Fyem bJ, <br /> C-) <br /> /�Y-vVe Uy- IR <br /> Inspection Date C -7 <br /> CA q539 c) Time In Time Out <br /> Business Rep Title 0 AM 0 AM <br /> / : i & OPM -7 ® PM <br /> —y",I Not"'n e,- �l fir 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) 0 Active 0 Passenger 0 Generator 0 Outdoor <br /> 0 0 Closed * Altered A11A <br /> GPS Latitude 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 /> 0 New Tire Dealer Q Auto Repair Q Trucking Fleet 0 Government 0 Retrleader 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 m N <br /> 0 0 14 CCR§18459.1 -Tire Program ID Number from CalRecycle (Required for NOV or EXT) N0 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 <br /> 0 0 14 CCR§18460.2-Manifest System Requirements for Registered Waste Tire Haulers 0 Referred/CalRecycle Enforcement <br /> Uj <br /> Uj <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 0 in Compliance-No Violations <br /> 0 0 Other:§ <br /> Comments <br /> 01 /T <br /> Inspection Form Included: 0 <br /> Comments Included: 0 Bu * ess Rep's Siiu—r-e Phone Number s e or's$I na re - Phone Number <br /> Correct:0 Incorrect: M Z� q M L 1 2 3 ■ <br /> 62081 <br /> INSTRUCTIONS ON BACK A 1W <br /> EWhite Copy:CalRecycle Yellow Copy:Operator Pink Cop <br />