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Waste Tire Survey & Inspection Report inspection Report Number <br /> CalRecycle State of California 1 1 - 1176790 <br /> CalRecycle 181(Rev.10/10) Cui"�/ey Fo�^r w, gage 1 1 <br /> Dept.of Resources Recycling and Recovery(CalRecycle) V Y <br /> BLUE OR BLACK INK PEN <br /> Part A-Survey <br /> Business Profile Inspection Details <br /> TPID- Inspection Type(Fill one) <br /> Site Suffix: ' ` O 5 Q 0 Routine 0 Re-inspection 0 Referral 0 Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier: S a o J Q LA,1 n Cc,A 0 CHP 0 CalRecycle 0 Complaint 0 Educational Visit 0 Other <br /> Business or Facility Name Inspected By Inspector <br /> Physicaress ` 1 O <br /> Inspection Date � / 0 <br /> \Je,� Time In Time Out <br /> Business Rep Title 0 r � AAM � ®AM <br /> `J Q PM I �l O 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 0 Pas ginger 0 Generator 0 Outdoor <br /> - - - -- - - r 1N 7 �I <br /> O 0 Closed 0 Alte ed/q / <br /> GPS Latitude 0 Hauler 0 Indoor <br /> O 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 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 NIA IA <br /> Part B - Inspection of Waste Tire Dealer, Generator, Hauler and End-Use Facility ENFORCEMENT STATUS <br /> V A HAULING AND MANIFEST REQUIREMENTS <br /> 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 <br /> 0 0 14 CCR§18459.2.1 -Submittal of Comprehensive Trip Logs within 90 days (Required for NOV or Exr) N <br /> n <br /> N <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 /> u <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 o <br /> 0 0 Other:§ l L 1 L <br /> Comments L•n!_ W619��t t 1(1yD � dT`C�1� ��, t� CCAiuy� l lf>r i��Ll1W1 f1U ( �Ll s cva J' <br /> 0i c ' <br /> Inspection Form Included: 0 Ppi� � � <br /> Comments Included: 0 ��— ( �— , <br /> Business Rep's Signature Phone Number Inspe is Signature Phone Number <br /> INSTRUCTIONS ON BACK Correct:0 Incorrect: V E JEJ 111213 62081 <br /> ® White Copy:CalRecycle Yellow Copy:Operator Pink Copy:LEA © ■ <br />