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/ r : . <br /> Waste Tire Survey & Inspection Report Inspection Report Number <br /> CalRecycle State of California _ I 1 - 1176786 <br /> CalRecycle181(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- Inspection Type(Fill one) <br /> Site Suffix: t `I V L ® Routine 0 Re-inspection 0 Referral 0 Observation <br /> Locall (i1 If Referral,choose referral type(Fill one) <br /> Identifier: S G(,(� V �( lel►f1 w u 0 CHP 0 CalRecycle 0 Complaint 0 Educational Visit 0 Other <br /> Business or Facility Name Inspected By Inspector <br /> SAm 0 50or �le� G _ T <br /> Physical Address S I I � V <br /> V Inspection Date l <br /> dov,� Time In Time Out <br /> Title + I : J, S O AM �, SAM <br /> Business Rep 1 1 PM PM <br /> Ch C S I'L Orf1 U,rc. - <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) , <br /> Active 0 Passenger ® Generator 0 Outdoor <br /> O 0 Closed 0 Altered q <br /> GPSLatitude 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 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 41 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 <br /> M / m / m <br /> N <br /> 0 0 14 CCR§18459.1 -Tire Program ID Number from CalRecycle <br /> 0 0 (Required for NOV or EXE N <br /> 14 CCR§18459.2.1 -Submittal of Comprehensive Trip Logs within 90 days v <br /> 0 0 14 CCR§18459.3-Retention of Comprehensive Trip Logs for 3 years o <br /> 0 00 Referred/CalRecycle Enforcement <br /> 14 CCR§18460.2 Manifest System Requirements for Registered Waste Tire Haulers 2 <br /> Lu <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 <br /> in Compliance-No Violations o <br /> 010 Other:§ _ <br /> Comments <br /> Novi() 1'0n�, 6J We46 &Cincafn <br /> Inspection Form�nc <br /> ncluded: 01 <br /> Comments luded:,4- <br /> Business Rep's Signature Phone Number Insp or's Signature — — _Phone Number <br /> — ,---- — 62081 <br /> INSTRUCTIONS ON BACK Correct:* Incorrect: E X A E 1 2 3 <br /> White Copy:CalRecycle Yellow Copy:Operator Pink C A © ■ <br /> ■ <br />