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- - ---­--------- <br /> ................ <br /> Waste Tire Survey & Inspection Report Inspection Report Number <br /> calRecycle State of California <br /> CalRecycle 181(Rev.10/10) 11 - 1177702 <br /> Dept of Resources Recycling and Recovery(CalRecycle) Survey Form - Page 1 BLUE OR BLACK INK PEN <br /> Part A-Survey <br /> Business Profile Inspection Details - <br /> TPID- Inspection Type(Fill one) <br /> Site Suffix: 1 - 0 1 OP Routine 0 Re-inspection 0 Referral 0 Observation <br /> LocalIf Referral,choose referral type(Fill one) <br /> Identifier: Sc,,m C,6, hl 0 CHP 0 CalRecycle 0 Complaint 0 Educational Visit 0 Other <br /> Business or Facility Name Inspected By Inspector <br /> k <br /> Physical Address <br /> kqn /Q&t.t4l c)r . Inspection Date <br /> 6A Time In Time Out <br /> Business Rep Title AM go AM <br /> 0 PM O c) 0 PM <br /> QK 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 /> ® Active ® Passenger 0 Generator ® Outdoor <br /> G pS Latitude 0 0 Closed 0 Altered 0 Hauler ® Indoor <br /> 0 0 Inactive 0 Truck <br /> Longitude 0 Planned 0 OTR 0 End-use 0 container <br /> Business Type(Fill all that apply) 0 Tire Derived Fuel <br /> 0 New Tire Dealer 0 Auto Repair 0 Trucking Fleet 0 Government 0 Retreader 0 Dismantler <br /> 0 Used Tire Dealer 49 Auto Body 0 Car Dealer 0 Collection 0 Crumb Rubber <br /> 0 service Station 0 Hauler 0 Agriculture 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 <br /> / m " <br /> 0 0 14 CCR§18459.1 -Tire Program ID Number from CalRecycle <br /> (Required for NOV or EX7) <br /> 0 0 14 CCR§18459.2.1 -Submittal of Comprehensive Trip Logs within 90 days (ReqN <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 /> Lu <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 0 Other:§ <br /> Comments <br /> Inspection Form Included: 04- <br /> Comments Included: 0B mess Rep' io'nature Phone Number In t S// re Phone Number <br /> 62081 <br /> INSTRUCTIONS ON BACK Correct:* incorrect:I P L�N E X A <br /> ■ White Copy:CalRecycle Yellow Copy:Operator Pink Co :L ® ■ <br />