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........ . . <br /> Waste Tire SLavey & Inspection Report Inspection Report Number ■ <br /> State of California <br /> CalRecycle CalRecycle 181(Rev.10/10) Survey Form - Pa <br /> 11 - 1210116 <br /> Dept.of Resources Recycling and Recovery(CalRecycle) <br /> ge 1 <br /> Part A-Survey BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- Inspection Type(Fill one) <br /> Site Suffix: w J O 0 0 Routine 0 Re-inspection 0 Referral 0 Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier: 50'0JO a kk i rA 0 CHP 0 CalRecycle 0 Complaint 0 Educational Visit 0 Other <br /> Business or Facility Name l Inspected By Inspector <br /> Physical Address <br /> X03 E M 1-n <br /> GAI Inspection Date <br /> Time In Time Out <br /> Business Rep Title 0 0 Am 0 AM <br /> 0 PM IN PM <br /> OWic- 70-4f)o 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 /> 0 Active 0 Passenger 9 Generator 0 Outdoor <br /> 0 0 Closed 0 Altered fl),lq <br /> GPS Latitude 0 0 inactive 0 Truck 0 Hauler 0 indoor <br /> Longitude 0 Planned 0 OTR 0 End-use 0 container <br /> Business Type(Fill all ttW apc*y, R.'AbIA <br /> 0 New Tire Dealer C) Aum Avow 0 Trucking Fleet 0 Government 0 Retreader 0 Dismantler 0 Tire Derived Fuel <br /> 0 Used Tire Dealer C ^M 1" 0 Car Dealer 0 Collection 0 Crumb Rubber <br /> 0 Service Station 0 mauw 0 Agriculture 0 Shredder 0 Other 31�,j M-4.n4k��_r <br /> Part B - Inspection of 1101111oaft Tire Dealer, Generator, Hauler and End-Use Facility ENFORCEMENT STATUS <br /> V A HAULING AND NWNIIIFEST 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-Peu=sible 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§184592.1 -Submittal of Comprehensive Trip Logs within 90 days (Required for NOV or EX7) N <br /> 0 0 14 CCR§18459.3-Retention of Comprehensive Trip Logs for 3 years 12 <br /> 0 0 14 CCR§18460.2-Manifest System Requirements for Registered Waste Tire Haulers 0 Referred/CalRecycle Enforcement 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 /> Commentsr^ D�Re"-On <br /> d, 411 <br /> No -41' A'AA4nns Of CA CC-CA S C& come M <br /> Inspection Form Included: 0 2y?'75c7f-75-11 .4 A)qb&_3)1j <br /> ( 10' <br /> Comments Included: I*- - <br /> BusinesVIR 's Signature - Phone Number Ins Wrl,Signature Phone Number <br /> 3 <br /> INSTRUCTIONS ON BAC Correct:Ob incorrect: JEJXJAJ 1 111213 62081 <br /> 1 <br /> White Copy:CalRecycle Yellow Copy:Operator Pink C0V ® ■ <br />