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® Waste Tire Survey & Inspection Report Inspection Report Number <br /> CalRecycle S1(tate of CaliforniaCel111 - 12 2 6 3 6 5 <br /> CalRecycle 181(Rev.10/10) Survey Form - Page 1 <br /> Dept.of Resources Recycling and Recovery(CalRecycle) <br /> BLUE OR BLACK INK PEN <br /> Part A-Survey <br /> Business Profile Inspection Details <br /> TPID- ` 11 C O ,l - Q l Inspection Type(Fill one) <br /> Site Suffix: I 1 J ® Routine 0 Re-inspection 0 Referral 0 Observation <br /> Local / If Referral,choose referral type(Fill one) <br /> Identifier: S4 n J Ua�U t n (i)t'u 0 CHP 0 CalRecycle 0 Complaint 0 Educational Visit 0 Other <br /> Business or Facility Name Inspected By Inspector <br /> Physical Address 0 1 stb tJ <br /> a%bn S C, fJolCJn _ <br /> Inspection Date / d 5 <br /> 'YVID C A q s ao l <br /> Time In Time Out <br /> Business Rep Title � O AM 0 , O AM <br /> PM V PM <br /> - <br /> Cv�n�; <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 /> �J 0 Active 0 Passenger 0 Generator 0 Outdoor <br /> O 0 Closed 0 Altered N A <br /> GPS Latitude 0 Hauler 0 Indoor <br /> O Q Inactive 0 Truck <br /> Longitude - 0 Planned ® OTR 0 End-Use 0 Container <br /> Business Type(Fill all that apply) r __ <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 <br /> Part B- Inspection of Waste Tire Dealer, Generator, Hauler and End-Use Facility ENFORCEMENT STATUS <br /> VI A HAULING AND MANIFEST REQUIREMENTS <br /> 0 Notice Of Violation Q Extension <br /> 0 0 <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 /> 0 0 PRC§42956-Registration/Decal in Vehicle <br /> 00 14 CCR§18459-Responsible Entities Complying with Manifesting Requirements Date Ffl / m / Ffl <br /> 0 0 14 CCR§18459.1 -Tire Program ID Number from CalRecycle 3 <br /> 0 0 14 CCR§18459.2.1 -Submittal of Comprehensive Trip Logs within 90 days (Required for NOV or EXE N <br /> 0 0 14 CCR§18459.3-Retention of Comprehensive Trip Logs for 3 years o <br /> 0 0 14 CCR§18460.2-Manifest SysteRi Requirements for Registered Waste Tire Haulers 0 Referred/CalRecycle Enforcement <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 o <br /> 0 0 Other:§ <br /> Comments LIC. fie. )n5Un n0 b!1 �f�j S / y GYII� ►'12� "i0��U W��� <br /> U5 0 > �►' - --- <br /> IV� yi0�1-kb-0 6f -o-Ks U� co-r)cern. <br /> Inspection Form Included: 0 <br /> Comments Included: ® � �v <br /> Business Rep's Signature Phone Number Inspe or's Signature Phone Number <br /> — 62081 <br /> INSTRUCTIONS ON BACK Correct:18 Incorrect: E X P E 1 2 3 <br /> ■ White Copy:CalRecycle Yellow Copy:Operator Pi y:I FA © ■ <br />