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'Aso\ <br /> Waste Tire Sley & Inspection Report Inspection Report Number <br /> � <br /> CalRecycle State of California <br /> CalRecycle 181(Rev.10/10) I 1 - 1230052 <br /> Survey Form - Page 1 <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- Inspection Type(Fill one) <br /> Site Suffix: ` 3 I 1 '0 Routine 0 Re-inspection 0 Referral 0 Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier: ��p�Q��� C��(� { 0 CHP 0 CalRecycle 0 Complaint 0 Educational Visit 0 Other <br /> Business or Facility Name 4 ( Inspected By Inspector <br /> N11- C-m\ <br /> Physical Address <br /> 3'2 2� S VVv-j ON - -- - — <br /> ``e t � � 2� � Inspection Date � (-{ / O I / <br /> ' Lv i-U h C Time In L Time Out <br /> Title AM <br /> AM <br /> Business Rep ` 1 b O PM 2 ®PM <br /> 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 /> 40 Active 0 Passenger 0 Generator 0 Outdoor <br /> 0 0 Closed 0 Altered )0 lA <br /> GPS Latitude 0 Hauler 0 Indoor <br /> 0 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 *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 00 Other <br /> Part B- Inspection of Waste Tire Dealer, Generator, Hauler and End-Use Facility ENFORCEMENT STATUS <br /> V A HAULING AND MANIFEST REQUIREMENTS <br /> 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 / 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 /> 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 <br /> �Pl 2c <br /> �_� a.� Tin e 'C-o�,�C�� '�_ l�O►-S 1(1� 'c�� f <br /> CLS Cef' <br /> Inspection Form Included: 0 hV — 17-Y6 <br /> Comments Included: - �� <br /> Business Rep's I ature Phone Number Inspec is Signature Phone Number <br /> 62081 <br /> INSTRUCTIONS ON BACK Correct:I. Incorrect: EXAMPLE 1 111213 <br /> . White Copy:CalRecycle Yellow Copy:Operator Pink Copy:LEA ® 0 <br />