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Waste Tire Survey & Inspection Report -Inspection Report Number <br /> State of California <br /> CalRecycle CalRecycle 181(Rev.10/10) 11 -1176811 <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- I <br /> inspection Type(Fill one) <br /> Site Suffix: l 3 lQ O 9 Routine 0 Re-inspection 0 Referral 0 Observation <br /> Localif Referral,choose referral type(Fill one) <br /> identifier: ttlf\ 0 CHP 0 CalRecycle 0 Complaint 0 Educational Visit 0 Other <br /> Business r acility Name Inspector <br /> F Inspected By <br /> i ct�e <br /> Physical Address <br /> Inspection Date / I _ / O <br /> GA JS gLID Time In Time Out <br /> Business Rep Title 0 AM 0 AM <br /> 46 PM 0 40 P M <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) <br /> 0 Active 0 Passenger 0 Generator 0 Outdoor <br /> 0 0 Closed 0 Alt'e <br /> PS Latitude )IA 0 H qa l/ <br /> 0�IoAr <br /> G 0 0 inactive 0 Truck 0 End-use 0 container <br /> Longitude 0 Planned 0 OTR <br /> Business Type(Fill all that apply) <br /> 0 New Tire WDeale�ro Auto Repair 0 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 Is Other S1'u <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 /> 6 5 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 /> 0 0 14 CCR§18459.1 -Tire Program ID Number from CalRecycle <br /> (Required for NOV or EX7) <br /> N0 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 <br /> In Compliance-No Violations <br /> 10 1 0 1 Other:§ <br /> Comments <br /> r--N7 (q) f L <br /> Inspection Form Include '0W0 <br /> Comments Incl ed: 0 Busi Rep's Signature one Number Ins tor's Signature hone Number <br /> 1112131 <br /> 62081 <br /> INSTRUCTIONS ON c : Incorrect: E X A M JEJ <br /> ■ White Copy:CalRecycle Yellow Copy:Operator Pink Co y:L ® ■ <br />