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' <br /> Waste Tire Su. Bey & Inspection Report inspection Report Number <br /> CalRecycle State of California 1 - 1210117 <br /> CalRecycle 181(Rev.10/10) 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- Inspection, 3 _ Inspection Type(Fill one) <br /> Site Suffix: V' 0 Routine 0 Re-inspection 0 Referral 0 Observation <br /> Local j If Referral,choose referral type(Fill one) <br /> Identifier: u{1 �U�,�u,n ���/� 0 CHP 0 CalRecycle 0 Complaint 0 Educational Visit 0 Other <br /> Business or Facility Name (� Inspected By Inspector <br /> - <br /> Physical Address 1 v C�TT- <br /> 30350 S_�('cc,c� v�- <br /> Inspection Date <br /> Time In Time Out <br /> Business Rep Title1 -'�,, O AM O AM <br /> M <br /> SOYL � F 1 '` ) 1kn1 G O A PM 3 "► e 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 /> ® Active 0 Passenger Generator ® Outdoor <br /> O 0 Closed 0 Altered <br /> GPS Latitude 0 Hauler 0 Indoor <br /> 0 0 Inactive 10Truck <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 ® 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 y <br /> 0 Service Station 0 Hauler 0 Agriculture 0 Shredder S.Other Coc)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 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 /> PRC§42956-Registration/Decal in Vehicle <br /> 00 14 CCR§18459-Responsible Entities Complying with Manifesting Requirements Date M / M / Ffl <br /> a <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 EX7) <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 ®In Compliance-No Violations o <br /> 1010 Other:§ <br /> Comments -f� (�efil �VGt`1 P-A � (A1Q 6 . -r,, -A p5p Ln 'CA 19�, '�Yl;c <br /> �0N\0V'3 utAs <br /> � �,�� <br /> tption Form Included: 0omments Included: <br /> Business Rep's Signature —Phdfie Number Insp tor's Signature Phone Number <br /> INSTRUCTIONS ON BACK Correct:I* Incorrect: g EXAM L 1 2 3 62081 <br /> ■ White Copy:CalRecycle Yellow Copy:Operator Pink CopL- V <br /> ® 0 <br />