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Waste Tire Survey & Inspection Repot Inspection Report Number <br /> State of California 11 - 1245120 <br /> CalRecycle CalRecycle 181(Rev.10/10) Page I <br /> Dept of Resources Recycling and Recovery(CalRecycle) BLUE <br /> Form BLUE OR BLACK INK PEN <br /> Part A-Survey <br /> Business Profile Inspection Details <br /> TPID- inspection pe(Fill one) <br /> Site Suffix: o Type <br /> 40 Routine 0 Re-inspection 0 Referral 0 Observation <br /> Local it Referral,choose referral type(Fill one) <br /> Identifier V�V) 0 CHIP 0 CalRecycle 0 Complaint 0 Educational Visit 0 Other <br /> 77�0" <br /> Business or FacilityNamer Inspected By Inspector <br /> Ec-f-0 co�F> <br /> Pfiysical Address3 <br /> Inspection Date t z <br /> 57Z0 5- Time In Time Out <br /> Business Rep Title20 AM Z_ 5_(3 0 AM- • 0 0 PM Is PM <br /> '5-0-8- <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) 0 Active 0 Passenger 41 Generator 0 Outdoor <br /> 0 0 Closed 0 Altered <br /> GPS Latitude 0 Hauler 0 indoor <br /> 0 0 Inactive 0 Truck <br /> Longitude 0 Planned IS OTR 0 End-use 0 container <br /> Business Type(Fill all that apply) <br /> 0 New Tire Dealer Q 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 40 Other &4j* <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 Datem <br /> 0 0 14 CCR§18459-Responsible Entities Complying with Manifesting Requirements <br /> / m / <br /> 0 0 14 CCR§18459.1 -Tire Program ID Number from CalRecycle <br /> (Required for NOV or EXT) i4 <br /> 0 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 /> Uj <br /> 0 0 14 CCR§18461 -Manifest System Requirements for Waste Tire End-Use Facilities <br /> 0 0 14 CCR§16462-Manifest System Requirements for Tire Dealers or Waste Tire Generators in compliance-No Violations <br /> 10 1 0 Other:§ <br /> Comments �[CO;5:6 -tLL 1AL-A lu <br /> P16 <br /> Inspection Form Included: 0 9 99S jog At(f-2 0: <br /> ,d: 0(—;, 'f 1 0 :4 — <br /> Comments Include, Phone Number <br /> Business Rep's Signature Phone Number nspector's Signature 62081 <br /> INSTRUCTIONS ON BACK FCorrect,0 Incorrect, X EXAMPLE I 11 2 3 ■ <br /> ■ White Copy:CalRecycle Yellow Copy:Operator Pink Copy:LEA <br />