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Waste Tire Survey & Inspection Report Inspection Report Number <br /> State of California <br /> CalRecycle CalRecycle 181(Rev.10/10) 11 - 1242089 <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- <br /> Inspection Type(Fill one) <br /> 1 Site Suffix: 6 Routine 0 Re-inspection 0 Referral 0 Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier: 0 CHP 0 CalRecycle 0 Complaint 0 Educational Visit 0 Other <br /> Business or Facility Name Inspected By Inspector <br /> .5ioc\f- v-, AT <br /> ko <br /> Physi Address "T \3 <br /> ?I$SO Ce_W,e7\\0_C1_/ ULY-, Inspection Date LA <br /> S4oc,vkoy-\ Time In Time Out <br /> Business Rep TitleAM 0 AM <br /> (-) : � & 0 PM 0 PM <br /> a3p—y\ 4;0��CvAtziness Role Storage Type <br /> Lor Operational Status Tire Type Bus <br /> Tire Count (Whole/PTE) (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> 4&Active 0 Passenger 0 Generator 0 Outpor <br /> 0 0 Closed 0 Altered <br /> GPS Latitude 0 Hauler 0 Indoor <br /> 0 0 inactive 0 Truck <br /> Longitude 0 Planned 0 OTR 0 End-Use 0 container <br /> Business Type(Fill all that apply) 41".0c <br /> 0 New Tire Dealer 0 Auto Repair 0 Trucking Fleet 0 Government 0 Retreader Q 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 a 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 / m <br /> 0 0 14 CCR§18459.1 -Tire Program ID Number from CalRecycle <br /> (Required for NOV or EXT) <br /> N0 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 /> 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 10 in compliance-No Violations <br /> 0 0 Other:§ <br /> Comments <br /> 0� <br /> Inspection Form Included: 0 <br /> Comments Included. 1w - <br /> Business Rep's S atur Phone Number Inspe or s Signature Phone Number <br /> M /Z�. 62081 <br /> INSTRUCTIONS ON BACK Correct: Incorrect: E X A M P L E 1 2 3 <br /> White Copy:CalRecycle Yellow Copy:Operator Pink Copy:LEA <br />