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a <br />Waste Tire Su, vey & Inspection Report Inspection Report Number ■ <br />State of California <br />Cal RecycleI 1 1196708 <br />CalRecycle 181 (Rev. 10/10) <br />(Cal Survey Form - Page 1 <br />Dept. of Resources Recycling and Recovery(CalRecycle) <br />)art A - Survey BLUE OR BLACK INK PEN <br />Business Profile �j Inspection Details <br />ete Suffix: � <br />Si . q -1 <br />Local <br />Identifier: ay` <br />Business or Facility Name <br />5 �© cV\Crv\ <br />Physical Address <br />IZ`-AO �3ooy <br />1 '3 4 0 1 <br />C-0"All <br />� CC""z 5 <br />5kOle \-OY-\ <br />Business Rep <br />Ldv', e L.w Ma-Crc,� <br />Tire Count (Whole/PTE) <br />GPS Latitude <br />Longitude <br />Business Type (Fill all that apply) <br />0 New Tire Dealer 0 Auto Repair <br />0 Used Tire Dealer 0 Auto Body <br />0 Service Station 0 Hauler <br />C P� �520� <br />Title <br />DA V eP_A NC - <br />s <br />Operational Status <br />Tire Type <br />Business Role <br />Storage Type <br />O <br />(Fill all that apply) <br />(Fill all that apply) <br />0 <br />4F Trucking Fleet <br />0 Car Dealer <br />0 Agriculture <br />Inspection Type (Fill one) <br />0 Routine 0 Re -inspection 0 Referral 0 Observation <br />If Referral, choose referral type (Fill one) <br />0 CHP 0 CalRecycle 0 Complaint 0 Educational Visit 0 Other <br />Inspected By Inspector <br />Ct - 1 d1P�T'S'v <br />Inspection Date <br />Time In Time Out <br />0 AM z 0 AM <br />l rJ 0 PM J 0 PM <br />Operational Status <br />Tire Type <br />Business Role <br />Storage Type <br />(Fill one only) <br />(Fill all that apply) <br />(Fill all that apply) <br />(Fill all that apply) <br />0 Active <br />0 Passenger <br />0 Generator <br />0 Outdoor <br />0 Closed <br />0 Altered <br />Hauler <br />00 Indoor <br />0 Inactive <br />40 Truck <br />(Required for NOV or EX7) <br />0 Planned <br />0 OTR <br />0 End -Use <br />0 Container <br />U Government U Retreader <br />0 Collection 0 Crumb Rubber <br />0 Shredder 0 Other <br />Dismantler i_) Tire Derived Fuel <br />Part B - Inspection of Waste Tire Dealer, Generator, Hauler and End -Use Facility <br />ENFORCEMENT STATUS <br />V A HAULING AND MANIFEST REQUIREMENTS <br />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. <br />Compliance Deadline <br />0 0 PRC § 42956 - Registration/Decal in Vehicle <br />0 0 14 CCR § 18459 - Responsible Entities Complying with Manifesting Requirements <br />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 <br />(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 <br />0 Referred / CalRecycle Enforcement <br />0 0 14 CCR § 18461 - Manifest System Requirements for Waste Tire End -Use Facilities <br />_ <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 �\�V� �s O..�a� �•`c'� �Y�� �G��y` c"�1p�Q O V� 'M�,., <br />Inspection Form Included: 0 q 5_jW _qo` <br />Comments Included: <br />La4 J 496�_ <br />Business Rep's Signature U Phone Number Inspe tor's Signature <br />INSTRUCTIONS ON BACK I Correct: Incorrect: E I X I A IM I P I L I E I 1112 3 <br />® White Copy: CalRecycle Yellow Copy: Operator Pink Copy: LEA <br />1g-6 R4 <br />Phone Number <br />62081 <br />■ <br />LU <br />W <br />