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.......... ... ....... <br /> .............. . .... . <br /> Waste Tire Survey & Inspection ReportI rispection Report Number <br /> State of California <br /> Cal Recycle CalRecycle 181(Rev.10/10) 11 - 1177710 <br /> Dept.of Resources Recycling and Recovery(CalRecycle) Survey Form - Page 1 <br /> Part A-Survey BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- Inspection Type(Fill one) <br /> Site Suffix: 1 0 Qj Routine 0 Re-Inspection 0 Referral 0 Observation <br /> LocalIf Referral,choose referral type(Fill one) <br /> Identifier: SCLr\, 0 CHP 0 CalRecycle 0 Complaint 0 Educational Visit 0 Other <br /> Business or Facility Name Inspected By Inspector <br /> Physical Address Ai7iIA-m L)LA <br /> --gc"_7 <br /> Inspection Date <br /> 6A Time In Time Out <br /> Business Rep Title 0 AM 0 AM <br /> 0 Pm j -7 ® 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 /> —151— 1&Active 0 Passenger (ID Generator 0 Outddoyr,_ <br /> 0 0 Closed 0 Altered <br /> GPS Latitude 0 Hauler 0 indoor <br /> 0 0 Inactive 0 Truck <br /> Longitude 0 Planned 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 a 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 PRC§42951 -Waste Tire Hauler Registration and Transport of Tires 0 Notice Of Violation 0 Extension <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 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 EXT) c� <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 <br /> 0 0 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators <br /> in Compliance-No Violations <br /> 0 1 0 1 Other:§ <br /> Comments <br /> Inspection Form Included: 0 <br /> 32Z6 <br /> Comments Included: <br /> 474s_ <br /> 1346ines_hjKep's Sig'natLde Phone Number Ins actops igat# Phone Number <br /> z 1 1 62081 <br /> INSTRUCTIONS ON�A orrect:0 Incorrect: q EXAM 1112131 <br /> 0 White Copy:CalRecycle Yellow Copy:Operator Pink C 0 <br />