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----------------- <br /> 02 Waste Tire%ey & Inspection Rep Inspection Report Number <br /> State of California <br /> CalRecycle CalRecycle 181(Rev.10/10) - 1176372 <br /> - <br /> Dept.of Resources Recycling and Recovery(CalRecycle) 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: Routine 0 Re-inspection 0 Referral 0 Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier: S&o 1A1 0 0 CHP 0 CalRecycle 0 Complaint 0 Educational Visit 0 Other <br /> Business or Facility Na e Inspected By Inspector <br /> Tru 4 Ze(� MoAt- f- <br /> Physical Address 3 Es Ab <br /> � I� E. e,l��.r�-e.� w - <br /> Inspection Date <br /> SAO 0�0 1-1 Time In Time Out <br /> Business Rep Title fil AM AM <br /> 5 0 PM I Q 0 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) 3 O 0 Active 0 Passenger 6 Generator 0 Outdoor <br /> pS Latitude 0 Closed 0 Altered 0 Hauler 0 indoor <br /> G 0 0 Inactive 0 Truck 0 End-use 0 container <br /> Longitude 0 Planned 0 OTR <br /> Business Type(Fill all that apply) <br /> New Tire Dealer 0 Auto Repair 0 Trucking Fleet 0 Government 0 Retreader 0 Dismantler 0 Tire Derived Fuel <br /> 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 <br /> c') <br /> 0 0 14 CCR§18459.1 -Tire Program ID Number from CalRecycle <br /> (Required for NOV or EX7 <br /> N <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 In Compliance-No Violations <br /> _j <br /> 010 1 Other:§ <br /> Comments ) 'NIL- <br /> ion (A <br /> Inspection Form Included: <br /> Comments Included: sines S' natur Pone Number Inspec rsSignature _P one <br /> Number <br /> 4 62081 <br /> �orrect:� incorrect:INSTRUCTIONS ON BA KX 7y E X A M <br /> NWhite Copy:CalRecycle Yellow Copy:operator Pink Co M <br />