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Waste Tire Su, vey & Inspection Report Inspection Report Number <br /> cle State of California <br /> Cal Rec <br /> Y CalRecycle 181(Rev.10/10) Survey Form - Page 1 11 - 1210371 <br /> Dept.of Resources Recycling and Recovery(CalRecycle) <br /> Part A-Survey BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- inspection a o 1 Inspection Type(Fill one) <br /> Site Suffix: • Routine 0 Re-inspection 0 Referral 0 Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier: 11Y���X 0 CHP 0 CalRecycle 0 Complaint 0 Educational Visit 0 Other <br /> Business or Facility Name Inspected By Inspector <br /> _ 1 T A A , \ <br /> Physical Address 7 l L A4 A v <br /> 57 -ACk St <br /> Inspection Date <br /> T���y Ck qs3�7 <br /> Time In Time Out <br /> Business Rep Title 1 O AM � � � Q O AM <br /> PM 18 PM <br /> Operational Status Tire Type Business Role Storage Type <br /> Tire Count (Whole/PTE) S' V (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> v *Active 0 Passenger 0 Generator . Outdoor <br /> O 0 Closed 0 Altered <br /> GPS Latitude 0 Hauler 0 Indoor <br /> O 0 Inactive Q Truck <br /> Longitude - 0 Planned • OTR 0 End-Use 0 Container <br /> Business Type(Fill all that apply) "-C tree_ <br /> 0 New Tire Dealer 0 Auto Repair 0 Trucking Fleet 0 Government 0 Retreader V0 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 I&Other <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 0 - 0 Notice Of Violation 0 Extension <br /> 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 N <br /> 0 0 14 CCR§18459.2.1 -Submittal of Comprehensive Trip Logs within 90 days (Required for NOV or EXT) <br /> a <br /> 0 0 14 CCR§18459.3-Retention of Comprehensive Trip Logs for 3 years o <br /> 0 0 14 CCR§18460.2-Manifest System Requirements for Registered Waste Tire Haulers 0 Referred/CalRecycle Enforcement <br /> 2 <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 o <br /> 0 0 Other:§ <br /> Comments <br /> .W c�-�� _ <br /> 0.,v' - 2 ��Aw rS_ C-Syao <br /> O �t*J�t�l��c9riS O C��S t C0y5 r-e-C yl <br /> Inspection Form Included: 0 r <br /> Comments Included: 41k- 22 <br /> - v __ �^�o�'� � <br /> usiness p's Signature Phone Number Inspector's Signature Phone Number <br /> �-,( 62081 <br /> X �J <br /> INSTRUCTIONS ON BACK Correct:I* Incorrect: EXAMPLE 1112 3 <br /> White Copy:CalRecycle Yellow Copy:Operator Pink Copy:LEA ® ■ <br />