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Waste Tire Survey & Inspection Report inspection Report Number <br /> CalRecycle st-te-,c-lifornia 11 - 1176810 <br /> CalRecycle 181(Rev.10/10) <br /> Dept.of Resources Recycling and Recovery(CalRecycle) Survey <br /> Form - Page 1 BLUE OR BLACK INK PEN <br /> Part A-Survey <br /> Business Profile Inspection Details <br /> TPID- I,, <br /> Inspection Type(Fill one) <br /> Site Suffix: 6 Routine 0 Re-inspection 0 Referral 0 Observation <br /> If Referral,choose referral type(Fill one) <br /> Oct� Ltl D 0 <br /> C 0 CHP 0 CalRecycle 0 Complaint 0 Educational Visit 0 Other <br /> Local <br /> Identifier: <br /> Business or Facility Name Inspected By Inspector <br /> SQx(.) r" UT'0 (j- - () ) <br /> Physical Address <br /> 4q _&'n F_�'- <br /> Inspection Date <br /> 0 ^ Time In Time Out <br /> Business Rep Title 0 AM D 0 AM <br /> PM PM <br /> Operational Status Tire Type Business Role Storage Type <br /> (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> Tire Count (Whole/PTE) ® Active 0 Passenger 6 Generator 0 Outdoor <br /> GPS Latitude 0 0 Closed 0 Altered 0 Hauler I 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) <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 0 Other LJAM�tj_ <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 /> 00 14 CCR§18459-Responsible Entities Complying with Manifesting Requirements Date m N <br /> 0 0 14 CCR§18459.1 -Tire Program ID Number from CalRecycle <br /> (Required for NOV or EXT) 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 /> Lu <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 <br /> 10 1 0 Other:§ <br /> _cv_�C_ )' �'r e)�' - 0 - A �- � <br /> Comments -��, otic <br /> Mo \J "1 0 a �r-us u)S <br /> A&��of\s ),r, r n <br /> Inspection Form Included: 0 2,09_'H b-(; 565 <br /> R <br /> Comments Included: Phone Number lns�pectfls Signature Phone Number <br /> iBuineQsse�pp's Signature 62081 <br /> INSTRUCTIONS ON BACK Correct: incorrect' <br /> *- E X A P <br /> ■ <br /> [ K't M <br /> White Copy:CalRecycle Yellow Copy:Operator Pink Co <br />