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---- --------- --------- <br /> -.,-----­-�-Sm--- on a -uv <br /> Waste Tire Su' rvey & Inspection Report 'Inspection Report Number <br /> State of California <br /> CalRecycle CalRecycle 181(Rev.10/ 1 - 1196262 <br /> Dept of Resources Recycling and Recovery(Co)) <br /> (CalRecycle) <br /> Form - Page 1 <br /> Part A-Survey BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- Inspection Type(Fill one) <br /> Site Suffix: f _ Qb Routine 0 Re-inspection 0 Referral 0 Observation <br /> LocalIf Referral,choose referral type(Fill one) <br /> Identifier: Sayl 0 CHP 0 CalRecycle 0 Complaint 0 Educational Visit 0 Other <br /> Business or Facility Name Inspected By Inspector <br /> RCA'� (D� - i o ( A/-)/1-M <br /> Physical' <br /> hysical Address <br /> Inspection Date <br /> CA q5"-)06 Time In Time Out <br /> Business Rep Title OAM 0 AM <br /> to PM a PM <br /> fvv kw <br /> Operational Status Tire Type Business Role Storage Type <br /> L (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> Tire Count(Whole/PTE) 41 z;- ®Active 0 Passenger ® Generator 0 Outdoor <br /> GPS Latitude 0 0 Closed 0 Altered 4@ Hauler 0 indoor <br /> 0 0 Inactive 0 Truck <br /> Longitude 0 Planned 0 OTR 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 Other 0-TA. r.n Renht <br /> Part B - Inspection of Waste Tire Dealer, Generator, Hauler and End-Use Facility ENFORCEMENT STATUS <br /> V A HAULING AND MANIFEST REQUIREMENTS 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 /> 00 14 CCR§18459-Responsible Entities Complying with Manifesting Requirements Date M3 <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 EX7) N <br /> 10 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 /> 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 <br /> 0 0 Other:§ <br /> Comments <br /> Inspection Form Included: 0 L,__'JCf-\ Z, CLL, <br /> Comments included: 40 Business Rep's Signature Phone Number In-gecoeitsic -antlume Phone Number <br /> INSTRUCTIONS ON BACK Correct:0 incorrect: el EX A M L 1 M23 62081 <br /> ■ White Copy:CalRecycle Yellow Copy:Operator Pink Co :L © ■ <br />