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------------- - - -------- --- ---- ------ ---- --- - <br /> Waste Tire Su, vey & Inspection Report Inspection Report Number <br /> CalRecycle State of California <br /> CalRecycle 181(Rev.10/10) 1230416 <br /> Dept.of Resources Recycling and Recovery(Cal -(CalRecycle) <br /> Form Page 1 <br /> Part A BLUE OR BLACK INK PEN <br /> F_si <br /> Bu iness Profile Inspection Details <br /> TPID- _7 C> Inspection Type(Fill one) <br /> Site Suffix: 0 Routine 0 Re-inspection 0 Referral 0 Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier: 0 CHIP 0 CalRecycle 0 Complaint 0 Educational Visit 0 Other <br /> Business or Facility Name V Inspected By Inspector <br /> Physical Adress I <br /> C)6­4 -2, q - � 0 1 <br /> il <br /> Inspection Date Clli <br /> LtA-. Lr--1 952"iz Time In Time Out <br /> Business Rep Title 1 6 : 2 S *0 PM k I ' 0 5 *0 PNM <br /> V.�'f 0 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 /> S Active IR Passenger 0 Generator Outdoor <br /> GPS Latitude 0 0 Closed 0 Altered 0 Hauler 0 Indoor <br /> 0 0 Inactive Truck <br /> Longitude 0 PlannedOTR 0 End-Use 0 Container <br /> Business Type(Fill all that apply) kC&PC_r <br /> 0 New Tire Dealer 0 Auto Repair 07Truca­g gleet 0 Government 0 Retreader 0 Dismantler 0 Tire Derived Fuel <br /> 0 Used Tire Dealer 0 Auto Body 0 Car DeaW 0 Collection 0 Crumb Rubber <br /> 0 Service Station 0 Hauler 0 Agricunure 0 Shredder 0 Other <br /> Part B - Inspection of Waste Tire Dealer, Generator, Hauler and End-Use Facility ENFORCEMENT STATUS <br /> V I 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 <br /> 0 0 14 CCR§18459-Responsible Entities Complying with Manifesting Requirements Date M M <br /> 0 0 14 CCR§18459.1 -Tire Program ID Number from CalRecycle (Required for NOV or EX7) <br /> 0 0 14 CCR§18459.2.1 -Submittal of Comprehensive Trip Logs within 90 days 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 /> N <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 /> 0 in Compliance-No Violations <br /> 0 0 Other:§ <br /> Comments <br /> 2C <br /> _Ay,vQ4exL-ty\ �vve_ on <br /> �MA <br /> ov",s a <br /> Inspection Form Included: 0 <br /> Comments Included: *— <br /> Business Re s Signature Phone Number Inspeclor's ISignature Phone Number <br /> 62081 <br /> INSTRUCTIONS ON BACK FCorrec7V771n:cco�rrect-, �X �t�q E X I A I M P I L I E 1 2 3 <br /> ■ White Copy:CalRecycle Yellow Copy:Operator Pink Copy:LEA <br />