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02 Waste Tire Survey & Inspection Repor ., Inspection Report Number ■ <br /> State of California <br /> CalRecycle I 1 - 1242479 <br /> CalRecycle 181(Rev.10/10) <br /> y(Cal Survey Form - Page 1 <br /> Dept.of Resources Recycling and Recovery(CalRecycle) <br /> Part A-Survey BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- I ' _ Inspection Type(Fill one) <br /> Site Suffix: O © ( 6 Routine 0 Re-inspection 0 Referral 0 Observation <br /> LocalIf Referral,choose referral type(Fill one) <br /> Identifier: S CJll� J D11,1 11.1n C�{.1 0 CHP 0 CalRecycle 0 Complaint 0 Educational Visit 0 Other <br /> Business or Facility Name Inspected By Inspector <br /> F14'�cv1' � <br /> Physical Address 1 <br /> �o ea2�k 0� L A q S Z 15 Inspection Date <br /> Time In Time Out / <br /> Business Rep Title �,J AM S AM <br /> 1 0 ' l QPM O QPM <br /> CZ-bd yUs CL o* <br /> Operational Status Tire Type Business Role Storage Type <br /> Tire Count(Whole/PTE) �jf (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> SCJ 0 Active 0 Passenger 0 Generator 0 Outdoor) <br /> O 0 Closed 0 Altered 1`A <br /> GPS Latitude 0 Hauler 0 Indoor <br /> O Q Inactive � Truck <br /> Longitude - 0 Planned ® OTR 0 End-Use 0 Container <br /> Business Type(Fill all that apply) �� 1 <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 pl'41 <br /> Part B - Inspection of Waste Tire Dealer, Generator, Hauler and End-Use Facility ENFORCEMENT STATUS <br /> V A HAULING AND MANIFEST REQUIREMENTS <br /> 0 Notice Of Violation Q 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 /> M / m / m <br /> 0 0 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 EXE 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 /> 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 A In Compliance-No Violations o <br /> 010 Other:§ <br /> Comments �US �t r. �S 'kG 144 <br /> Inspection Form Included: 0/ i1 Z_ !{�j0 Ll <br /> Comments Included: 0 `1 <br /> Business Rep's Signa Phone Number Inspe is Signature Phone Number <br /> INSTRUCTIONS ON BACK Corr :9 Incorrect: � � V EII1XAM L 1 2 3 62081 <br /> ■ White Copy:CalRecycle Yellow Copy:Operator Pink Copy: E ® ■ <br />