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Waste Tire Su' rvey & Inspection Report Inspection Report Number <br /> State of California <br /> CalRecycle CalRecycle 181(Rev.10/10 11 - 1177774 <br /> Dept of Resources Recycling and Recovery(Cal(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: O C) t Routine 0 Re-inspection 0 Referral 0 Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier: SCUA C_fivV-� 0 CHIP 0 CalRecycle 0 Complaint 0 Educational Visit 0 Other <br /> Business or Facility Name Inspected By Inspector <br /> A ' <br /> Physical Address S t L) <br /> Inspection Date q <br /> Time In Time Out <br /> Business Rep Title ®AM a AM <br /> / 0 : 1-( 0 0 PM 5 0 PM <br /> kca�0 Alep7i <br /> \3 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 /> 0 Active 0 Passenger 0 Generator 0 Outdoor <br /> GPS Latitude 0 0 Closed 0 Altered 0 Hauler 0 indoor <br /> 0 0 inactive to Truck <br /> Longitude 0 Planned 0 OTR 0 End-use 0 container <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 <br /> 0 0 14 CCR§18459.1 -Tire Program ID Number from CalRecycle m / M / m <br /> (Required for NOV or EXT) <br /> 0 0 14 CCR§18459.2.1 -Submittal of Comprehensive Trip Logs within 90 days (Reqcli <br /> 0 0 14 CCR§18459.3-Retention of Comprehensive Trip Logs for 3 years U) <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 <br /> 10 1 0 1 Other:§ <br /> Comments <br /> Inspection Form Included: 0 <br /> Comments Included: Wf_VAT-76-737' <br /> Business Rep's Signature 'Phone Number _Wspej06r_s <br /> ,,gignVure Phone Number <br /> INSTRUCTIONS ON BACK �Correct:* Incorrect: qf Iz A 62081 <br /> E A 11213 <br /> ■ White Copy:CalRecycle Yellow Copy:Operator Pink Cog: ® ■ <br /> I< <br /> Vi <br />