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................. ---- -- <br /> 0a Waste Tire Survey & Inspection Report Inspection Report Number <br /> ■ <br /> M CalRecycle State of California1 11 - 1176468 <br /> CalRecycle 181(Rev.10/10) <br /> Dept.of Resources Recycling and Recovery(CalRecycle) BLUE <br /> Form - Page <br /> BLUE OR BLACK INK PEN <br /> Part A-Survey Inspection Details - <br /> Business Profile <br /> TPID- Inspection Type(Fill one) <br /> Site suffix: 8 31 ® Routine 0 Re-inspection 0 Referral 0 Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier: 0 CHP 0 CalRecycle 0 Complaint 0 Educational Visit 0 Other <br /> Business o fli N Inspected By <br /> .,r Faci ity Name Inspector <br /> Physical Address <br /> Inspection Date L L <br /> CA q_F;R15 Time In Time Out <br /> AM AM <br /> Business Rep Title <br /> 0 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) 9 9 0 Active 0 Passenger Generator 0 Outdpor <br /> 0 Closed 0 Altered 14 <br /> GPS Latitude 0 Hauler 0 Indoor <br /> 0 0 Inactive 0 Truck <br /> Longitude 0 Planned (j) OTR 0 End-Use 0 container <br /> Business Type(Fill all that apply) 0 Government 0 Retreader Dismantler 0 Tire Derived Fuel <br /> 0 New Tire Dealer 0 Auto Repair 0 Trucking Flee <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 (Juve�ov <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 M <br /> m m <br /> 0 0 14 CCR§18459.1 -Tire Program ID Number from CalRecycle <br /> (Required for NOV or EXT) N <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 /> 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 10 in compliance-No Violations <br /> 0 0 Other: <br /> Comments <br /> Inspection Form Included: 0 U9 3/--717-0 e1- <br /> Comments Included: (a B j ess R S_QinnnfijrP Phone Number I e or' Si a re Phone Number <br /> E X 1 2 3 62081 <br /> INSTRUCTIONS ON BACK <br /> Correct:0 incorrect: X E X M <br /> MWhite Copy:CalRecycle Yellow Copy:operator Pink C y:L <br />