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Waste Tire Survey & Inspection Report Inspection Report Nurriber <br /> CalRecycle State of California <br /> CalRecycle 181(Rev.10/10) 11 1226684 <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: C) S C1 1 0 Routine 0 Re-inspection 0 Referral 0 Observation <br /> Local ` If Referral,choose referral type(Fill one) <br /> Identifier: SCXVX )Mk_%�'� 0 CHP 0 CalRecycle,0 Complaint 0 Educational Visit 0 Other <br /> Business or Facility Name Inspected By Inspector <br /> Av�c k!f'PC'-1y- <br /> Physical Address A,, <br /> Inspection Date c) <br /> C Time Out <br /> CA L Time In AM AM <br /> Business Rep Title t QPM J 7 QPM <br /> �04 a, Z>C)V-X �e"Xc'-Vtl 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) c�j0 Active 0 Passenger Generator 0 Outdoor <br /> 0 0 Closed 0 Altered <br /> GPS <br /> Latitude 0 0 Inactive 0 Truck 0 Hauler 0 Indoor <br /> Longitude 0 Planned 0 OTR 0 End-use 0 container <br /> Business Type(Fill all that apply) 0 Government 0 Retrea er 0 Dismantler 0 Tire Derived Fuel <br /> 0 New Tire Dealer (V Auto Repair 0 Trucking Fleet <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 /> V 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 mM M <br /> 0 0 14 CCR§18459.1 -Tire Program ID Number from CalRecycle <br /> (Required for NOV or EXE <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 <br /> 0 0 14 CCR§18460.2-Manifest System Requirements for Registered Waste Tire Haulers 0 Referred CalRecycle Enforcement <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 0 in compliance-No Violations <br /> 0 0 Other:§ <br /> Comments <br /> Inspection Form Included: 0 _JOM77-of <br /> Comments Included:40 Business p's Signature Phone N-umber I pe to Si a re Phone Number I <br /> 11 62081 <br /> INSTRUCTIONS ON BACK <br /> F�orrect:0 Incorrect: E X A <br /> ■ White Copy:CalRecycle Yellow Copy:operator Pink Cop : © ■ <br />