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Waste Tire SU' rvey & Inspection Report Inspection Report Number <br /> CalRecycle State of California <br /> CalRecycle 181(Rev.10/10) 11 - 1196634 <br /> Dept of Resources Recycling and Recovery(CalRecycle) BLUE <br /> Form - Page I BLUE OR BLACK INK PEN <br /> Part A-Survey <br /> Business Profile Inspection Details <br /> TPID- Inspection Type(Fill one) <br /> Site Suffix- 0 1 16 Routine 0 Re-inspection 0 Referral 0 Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier �Y\ 0 CHP 0 CalRecycle 0 Complaint 0 Educational Visit 0 Other <br /> Business or Facility Name Inspected By Inspector <br /> Avx\ &CA I� <br /> Physical Address <br /> Inspection Date <br /> Time In Time Out <br /> Business Rep Title 0 AM 0 AM <br /> [ - S 6 0 PM 02 (9 Pm <br /> Operational Status Tire Type Business Role Storage Type' <br /> IL (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> Tire Count (Whole/PTE) 3 0 Active 0 Passenger ®Generator Outdoor <br /> 0 0 Closed 0 Altered <br /> GPS Latitude 0 Hauler 0 Indoor <br /> 0 0 inactive 0 Truck <br /> Longitude 0 Planned OTR 0 End-use 0 container <br /> Business Type(Fill all that apply) <br /> 0 New Tire Dealer 0 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 * Other zr6 'r meoa-/%44 V�<�_kc <br /> Part B- Inspection of Waste Tire Dealer, Generator, Hauler and End-Use Facility ENFORCEMENT STATUS <br /> V A I 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 / m <br /> 0 0 14 CCR§18459.1 -Tire Program ID Number from CalRecycle <br /> (Required for NOV or EXE0 0 14 CCR§18459.2.1 -Submittal of Comprehensive Trip Logs within 90 days <br /> is <br /> o 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 in compliance-No Violations <br /> .0 0 Other:§ <br /> Comments <br /> Inspection Form Included: 0k__ <br /> Comments Included: -Owo 2 V4.r 72 <br /> rusianessP4's Signature I Ph6ne Number '1rt4pjCtor*,§g_n9!�re Phone Number <br /> 62081 <br /> Correct:0 'Incorrect: —47 EXAM IP <br /> INSTRUCTIONS ON BACK � X y <br /> ■ White Copy:CalRecycle Yellow Copy:Operator Pink Copy:LEA © ■ <br />