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Waste Tire Survey & Inspection Report Inspection Report Number <br /> State of California <br /> CalRecycle CalRecycle 181(Rev.10/10) 11 - 1- 17682 .5 <br /> Dept.of Resources Recycling and Recovery(CalRecycle) <br /> Survey Form - Page 1 BLUE OR BLACK INK PEN <br /> Part A-Sury y --- <br /> Business Profile inspection Details <br /> TPID- 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: "�SCXACv_/)V-' CCX1V1 0 CHIP 0 CalRecycle 0 Complaint 0 Educational Visit 0 Other <br /> Business or Facility Name Inspected By Inspector <br /> Physics Address r <br /> Inspection Date <br /> CC C� &A qS3�)L Time In <br /> Time Out <br /> Business RepTitle 0 AM 0 AM <br /> PM go PM <br /> 1 All <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) 4) Active ® Passenger ® Generator 0 Outdoor <br /> 0 0 Closed 0 Altered <br /> GPS Latitude 0 0 Inactive 0 Truck 0 Hauler 140D Indoor <br /> Longitude 0 Planned 0 OTR 0 End-Use 0 container <br /> Business Type(Fill all that apply) — <br /> 7--Auto Repair 0 Trucking Fleet 0 Retreader Dismantler 0 Tire Derived Fuel <br /> 41 New Tire Dealer 0 0 Government <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 0 Other <br /> Part B- Inspection of Waste Tire Dealer, Generator, Hauler and End-Use Facility ENFORCEMENT STATUS <br /> _V74— 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 N <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 <br /> 0 0 14 CCR§18459.3-Retention of Comprehensive Trip Logs for 3 years ent <br /> 14 CCR§18460.2-Manifest System Requirements for Registered Waste Tire Haulers 0 Referred/CalRecycle Enforcement <br /> 0 0 Lu <br /> 0 0 14 CCR§18461 -Manifest System Requirements for Waste Tire End-Use Facilities <br /> 0 0 14 OCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators <br /> In compliance-No Violations <br /> 0 0 Other:§ <br /> 1 1 <br /> Comments <br /> C—,2j--4 41 <br /> Inspection Form Included: 0 <br /> Comments Included: Bu ness Rep's Signature Phone Number p Ig ture Phone Number <br /> INSTRUCTIONS ON BACK CorrectAp 62081 <br /> Incorrect: E A 1 2 3 <br /> MWhite Copy:CalRecycle Yellow Copy:operator Pink Copy: M <br />