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.............. -------- .. . . <br /> _Y. <br /> Waste Tire Survey & Inspection Report Inspection Report Number M <br /> State of California <br /> CalRecycle CalRecycle 181(Rev.10/10) Survey Form - Pa <br /> 11 - 1177619 <br /> Dept.of Resources Recycling and Recovery(CalRecycle) <br /> ge 1 <br /> Part A-Survey BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- Inspection Type(Fill one) <br /> Site Suffix: (0 C1 0- '1 a Routine 0 Re-inspection 0 Referral 0 Observation <br /> Local Sav\ oly_d If Referral,choose referral type(Fill one) <br /> Identifier: 0 CHP 0 CalRecycle 0 Complaint 0 Educational Visit 0 Other <br /> Business or Facility Name Inspected By Inspector <br /> pL'L�-, —1 <br /> Physical Address <br /> Inspection Date <br /> Time In Time Out 6 4J <br /> Business Rep Title 0 AM 0 AM <br /> PM C2_ l46 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 Passenger 0 Generator 41 Outdoor <br /> 0 0 Closed 0 Altered <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 a 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 <br /> / m <br /> 0 0 14 CCR§18459.1 -Tire Program ID Number from CalRecycle <br /> (Required for NOV or EX7)Req <br /> 0 0 14 CCR§18459.2.1 -Submittal of Comprehensive Trip Logs within 90 days ( N <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 /> 2 <br /> W <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 In Compliance-No Violations <br /> 0 0 Other:§ <br /> Comments <br /> Inspection Form Included: 0 3 4 J(o <br /> Comments Included: . <br /> Bdsifirgs-Rep's-Signature Phone Number 5"Pcto/Agnature Phone Number <br /> 0 ,\ , <br /> 62081 <br /> INSTRUCTIONS ON BACK [CorE X A L rect. Incorrect: XA lz� 1 2 3 <br /> J;rl <br /> White Copy:CalRecycle Yellow Copy:Operator Pink Co V M <br />