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Waste Tire S rey & Inspection Repor* Inspection Report Number <br /> Cal Recucle State of California — <br /> J CalRecycle 181(Rev.10/10) Survey Form - Page 1 11 1177704 <br /> Dept of Resources Recycling and Recovery(CalRecycle) <br /> Part A-Survey BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- Inspection Type(Fill one) <br /> Site Suffix: 3 �{ 6 3 c ® Routine 0 Re-inspection 0 Referral 0 Observation <br /> Local 1 If Referral,choose referral type(Fill one) <br /> Identifier: ' SOCt t/1'Y` Gpy !zy 0 CHP 0 CalRecycle 0 Complaint 0 Educational Visit 0 Other <br /> Business or Facility Name Inspected By Inspector <br /> Physical Ad r SS ��n���� 3 Ml�f�LILA <br /> Inspection Date / 0 -7 / <br /> Time In Time Out <br /> Business Rep Title IVAM (0 AM <br /> • 0 v QPM � d � � QPM <br /> X11 sn <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 /> ® Active 0 Passenger &Generator 0Outdoor <br /> O 0 Closed 0 Altered <br /> GPS Latitude 0 Hauler 0 Indoor <br /> O 0 Inactive © Truck <br /> Longitude - 0 Planned ® 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 io Other <br /> Part B - Inspection of Waste Tire Dealer,Generator, Hauler and End-Use Facility ENFORCEMENT STATUS <br /> V A HAULING AND MANIFEST REQUIREMENTS <br /> 0 0 - 0 Notice Of Violation � Extension <br /> PRC§42951 Waste Tire Hauler Registration and Transport of Tires <br /> 0 0 PRC§42953-Contracts with Registered Waste Tire Haulers. Compliance Deadline <br /> PRC§42956-Registration/Decal in Vehicle <br /> 00 14 CCR§18459-Responsible Entities Complying with Manifesting Requirements Date IT] / M / Ffl <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 orEXT) 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 /> 0 0 14 CCR§18461 -Manifest System Requirements for Waste Tire End-Use Facilities __ W <br /> 0 0 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators ®In Compliance-No Violations o <br /> 0 1 0 1 Other:§ <br /> Comments <br /> Inspection Form Included: 0 <br /> Comments Included: ® o� - <br /> Rusin ep's Sign4We Phone Number s cto S' ature Phone Number <br /> INSTRUCTIONS ON BA K [Correctt'e Incorrect: Xla� E X A L 11213 62081 <br /> White Copy"'Recycle Yellow Copy:Operator Piv ® 0 <br />