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Waste Tire Survey & Inspection Report Inspection Report Number <br /> CalRecycle State of California <br /> CalRecycle 181(Rev.10/10) 11 -1176837 <br /> Dept.of Resources Recycling and Recovery(Cal Survey Form - Page 1 BL BACK INK PEN <br /> part A-_Survey_______ — ------ -- -- -- ------- - <br /> Business Profile inspection Details <br /> TPID- <br /> Inspection Type(Fill one) <br /> KfW <br /> Site Suffix: Routine 0 Re-inspection 0 Referral 0 Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier: <br /> V1 Ct�)Y� '7yVj— 0 CHP 0 CalRecycle 0 Complaint 0 Educational Visit 0 Other <br /> Business or Facility Name Inspected By Inspector <br /> oC, <br /> f <br /> Physical Address 3 t A bu&- <br /> R,5' &-: , 1_0J -i <br /> ., Inspection Date <br /> LIN, <br /> C)(��I CA q,�dLlc) Time In Time Out <br /> Business Rep Title 0 AMO AM <br /> L : I FZ5 0)PM 5- 0 PM <br /> vo, <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) 4b Active 0 Passenger 0 Generator #Outdoor <br /> pS Latitude 0 0 Closed 0 Altered 0 Hauler 0 indoor <br /> G 0 0 inactive 0 Truck 0 End-Use 0 Container <br /> Longitude 0 Planned 0 OTR <br /> I Business Type(Fill all that apply) <br /> New Tire Dealer 0 Auto Repair 0 Trucking Fleet 0 Government 0 Retreader 0 Dismantler 0 Tire Derived Fuel <br /> ID <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 m m NM <br /> 0 0 14 CCR§18459.1 -Tire Program ID Number from CalRecycle <br /> (Required for NOV or EXT) <br /> ry <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 /> 2 <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 *in Compliance-No Violations <br /> 0 0 Other:§ <br /> Comments <br /> Inspection Form Included: 0 <br /> Comments Included: Phone Number <br /> Business Rep's Signature Phone Number Insp t r's Si at re 62081 <br /> M 111 <br /> INSTRUCTIONS ON BACK Correct: Incorrect: J E 1 2 3 <br /> �A 11 <br /> zX , <br /> M White Copy:CalRecycle Yellow Copy:operator Pink Co <br /> Z <br />