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Waste Tire Survey & Inspection Report Inspection Report Number ■ <br /> State of California <br /> CalRecycle CalRecycle 181(Rev.10/10) 11 - 1196350 <br /> Part A Dept of Resources Recycling and Recovery(CalRecycle) Survey Form - Page 1 BLUE OR BLACK INK PEN <br /> -Survey <br /> Business Profile Inspection Details <br /> TPID- inspection Type(Fill one) <br /> Site Suffix: 11f) Routine 0 Re-inspection 0 Referral 0 Observation <br /> Local < If Referral,choose referral type(Fill one) <br /> Identifier: 5�v\ 0 CHP 0 CalRecycle 0 Complaint 0 Educational Visit 0 Other <br /> Business or Facility Name Inspected By Inspector <br /> 'I PhysPhysicalAddIs s c:> <br /> 5a2.Z-7 N c <br /> Inspection Date <br /> Time In Time Out <br /> Business Rep Title 0 AM 2 0 AM <br /> • C) <br /> a PM 40 PM <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 /> 0 Active Passenger Generator 4@ Outdoor <br /> 0 0 Closed 0 Altered <br /> GPS Latitude 0 0 inactive 6 Truck 0 Hauler 0 Indoor <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 19 Other <br /> Part B- Inspection of Waste Tire Dealer, Generator, Hauler and End-Use Facility ENFORCEMENT STATUS <br /> V I A I 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 I 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 or EXT) 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 /> 2 <br /> LU <br /> 0 0 14 CCR§184.61 -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 /> 0 0 Other:§ <br /> Comments <br /> Inspection Formncuded: 0 <br /> Comments Included: 6 Icl <br /> B ness Rep's i nature Phone Number ',*p96(9rqX1gnAure Phone Number <br /> ?V /Z;N 1W 2 3 62081 <br /> INSTRUCTIONS ON BACK I Correct:40 vIncorrect: K qRAjMjWLjEj 1 1 1 <br /> ■ White Copy:CalRecycle Yellow Copy:Operator Pink Copy:LEA ® ■ <br />