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® Waste Tire Sii.. Vey & Inspection Report, Inspection Report Rurnber <br /> CalRecycle State of California ) _ st- 7 <br /> CalRecycle181(Rev.10/10 Survey Form - Page 1 t 8 i <br /> Dept.of Resources Recycling and Recovery(CalRecycle) <br /> BLUE OR BLACK INK PEN <br /> Part A-Survey <br /> Business Profile Inspection Details <br /> TPID- o Inspection'type(Fill one) <br /> Site Suffix: O O I ® Routine 0 Re-inspection 0 Referral 0 Observation <br /> Local70 I n If Referral,choose referral type(Fill one) <br /> Identifier: ao a�L l l n 1 C3U�{l 0 CHP 0 CalRecycle 0 Complaint 0 Educational Visit 0 Other <br /> Business or Facility Name ` Inspected By Inspector <br /> �n�� �(-�` p,I S D U2. C Jl <br /> Physical Address v &.nSco80 <br /> -M ofli <br /> Inspection Date <br /> d Time In t� Time Out <br /> Business Rep Title 0 AMI 0 AM <br /> DolA(� ® PM 0 ® PM <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) 3 <br /> Active 0 Passenger ® Generator 0 Outdoor <br /> 0 Closed 0 Altered <br /> GPS Latitude 0 Hauler IS Indoor <br /> O 0 Inactive !Truck <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 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 ® Other �q 11,4ifP,,,V4vj <br /> Part B - Inspection of Waste Tire Dealer, Generator, Hauler and End-Use Facility ENFORCEMENT STATUS <br /> V A HAULING AND MANIFEST REQUIREMENTS <br /> 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 / 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) N <br /> 0 0 14 CCR§18459.3-Retention of Comprehensive Trip Logs for 3 years o <br /> 0 0 14 CCR§18460.2-Manifest System Requirements for Registered Waste Tire Haulers 0 Referred/CalRecycle Enforcement <br /> Lu <br /> W <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 ®In Compliance-No Violations o <br /> 0 0 Other:§ <br /> Comments x A 4 re)ns iA11 A.O nA_ Uf1 743 s d lN`Fe (4 nz& T0�1 .19 Ltd�^\j _ <br /> - ------ 0yi° As (9 u l 9s c - r fern <br /> i^ <br /> Inspection Form Included: 0 , <br /> Comments Included: ® _ <br /> 2Gq-9tlf�-4,lrX1 � yUg-3 `7 <br /> ess p's Si a Phone Number Insp tor's Signature Phone Number <br /> -- 62081 <br /> INSTRUCTIONS BACK rect: Incorrect: E X A P 1 2 3 <br /> . White Copy:CalRecycle Yellow Copy:Operator Pink Co ® ■ <br />