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Waste Tire Survey & Inspection Report Inspection Report Number ■ <br /> State of California <br /> CalRecycle CalRecycle 181(Rev.10/10) 11 - 1176710 <br /> Dept.of Resources Recycling and Recovery(GaiRecycle) Survey Form - Page 1 BLUE OR BLACK INK PEN <br /> Part A-Survey <br /> Business Profile Inspection Details <br /> TPID- inspection Type(Fill one) <br /> Site Suffix: 4-1 0 5 ILI �( 5 - 0 (D Routine 0 Re-inspection 0 Referral 0 Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier: VV 6JLvt+z_/ 0 CHP 0 CalRecycle 0 Complaint 0 Educational Visit 0 Other <br /> Business or Facility Name Inspected By Inspector <br /> uc)e <br /> Physical Address r & C�'_ <br /> 105-C.) <br /> Inspection Date <br /> Time In i Time Out <br /> Business Rep Title0 AM 0 AM <br /> '711 c-,.r_D t <br /> Z. : 1S opm Z_ S -7 le Pm <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) 0 Active a Passenger le Generator 0 Outdoor <br /> 0 Closed 0 Altered <br /> GFS Latitude 0 Hauler 0 indoor <br /> 0 0 Inactive 0 Truck <br /> Longitude 0 Planned 0 OTR 0 End-Use (V 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 Hauler 0 Agriculture 0 Shredder (jD Other ( fie'c Veh I le- 1-ir-9-- <br /> 0 '�K_ - <br /> Part B - Inspection of Waste Tire Dealer, Generator, Hauler and Encl-Use Facility ENFORCEMENT STATUS <br /> 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 <br /> 0 0 14 CCR§18459.1 -Tire Program ID Number from CalRecycle <br /> (Required for NOV or EXT) C? <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 <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 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 Q)in compliance-No Violations <br /> '0 0 Other:§ <br /> Comments <br /> Inspection Form Included: (75 7 1311 <br /> Comments Included: a Business Re Signal ure Phone Number In a tor's igna re Phone Number <br /> ?V 62081 <br /> Fco <br /> INSTRUCTIONS ON BACK rre;t 0 Incorrect: 1W E X A <br /> ■ White Copy:CalRecycle Yellow Copy:operator Pink C y: © ■ <br />