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Waste Tire S vey & Inspection Repor► Inspection Report Number ■ <br /> CalRecycle State of California 11 - 1226331 <br /> CalRecycle 181(Rev.10/10) 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: 1 I � 1 $ � � O f ® Routine 0 Re-inspection 0 Referral 0 Observation <br /> Local -1 If Referral,choose referral type(Fill one) <br /> Identifier: Sill �Ock 110 r\ C6_k \\ 0 CHP 0 CalRecycle 0 Complaint 0 Educational Visit 0 Other <br /> Business or Facility Name '__' Inspected By Inspector <br /> _`(Ick r_y Ul s ctins I \ '�14enctn ce, 3 9 - 1 0 E� <br /> Physical Address zoo <br /> apps ktolnin <br /> �cx CA 93`17 Inspection Date _1 <br /> � / � I,� / <br /> Time In Time Out <br /> Title ®AM AM <br /> Business Rep I I 5 O PM ' I O 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) 4 <br /> ® Active 10 Passenger ® Generator 0 Outdoor <br /> 0 0 Closed � Altered <br /> GPS Latitude 0 Hauler 0 Indoor <br /> 0 0 Inactive ® Truck <br /> Longitude - 0 Planned ® OTR 0 End-Use Container <br /> Business Type(Fill all that apply) <br /> 0 New Tire Dealer 0 Auto Repair 0 Trucking Fleet • 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 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 <br /> 0 0 PR - 0 Notice Of Violation 0 Extension <br /> C§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 /> 0 0 14 CCR§18459.2.1 -Submittal of Comprehensive Trip Logs within 90 days (Required for NOV or EXT) 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 /> 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:§!1 <br /> ��p 1 l' 1 N <br /> Comments C: t n�iIx� j-ll �04Nv br1 ` f11S su�C QI f1 (/� ��ei <br /> 1 <br /> 'N0 \)tiv1" 1h iJ Cil_ fec�� O& Gj3J)_oeLn- - <br /> Inspection Form Included: 0 <br /> Comments Included:® -- - <br /> Bus ess Rep' gnature Phone Number Ins�191, ture _ Phone Number <br /> NJ EXAM PILE 1 112 3 62081 <br /> INSTRUCTIONS ON BACK Correct: Incorrect: I ■ <br /> : —__ .e o <br /> White Copy:CalRecycle Yellow Copy:Operator Pink Copy:LEA <br />