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Oa Waste Tire Survey & Inspection Report Inspection Report Number <br /> CalRecycle State of California <br /> Y CalRecycle 181(Rev.10/10) Survey Foam - Page 1 11 1230341 <br /> Dept.of Resources Recycling and Recovery(CalRecycle) <br /> Part A-Survey _ BLUE_ OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- Inspection_ O Inspection Type(Fill one) <br /> Site Suffix: , O Routine 0 Re-inspection 0 Referral 0 Observation <br /> Local [ r— I If Referral,choose referral type(Fill one) <br /> Identifier: J OM JOCt I,I>'� C(911�� 0 CHP 0 CalRecycle 0 Complaint 0 Educational Visit 0 Other <br /> Business or Facility Name ` Inspected By Inspector <br /> �JU S Sc,�,tt Ci, <br /> � <br /> Physical Address <br /> lu SOf ��� ' -- <br /> � e � �533 Inspection Date <br /> (N e <br /> Time In Time Out <br /> Business Rep Title O Al O AM <br /> T(i er'A U}Utivr�y- I S S PM I G PM <br /> D <br /> 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 Pafsenger 0 Generator 0 Outdoor <br /> - O 18 Closed 0 AAlt e� N> <br /> GFS Latitude 0 Haul�r,�j 0 Ind�r/� <br /> 0 0 Inactive 0 Truck -I 11 vv►► <br /> Longitude - 0 Planned 0 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 <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 - 0 Notice Of Violation 0 Extension <br /> § <br /> PRC 42951 Waste Tire Hauler Registration and Transport of Tires <br /> 0 0 PRC§42953-Contracts with Registered Waste Tire Haulers. Compliance Deadline <br /> PRC§42956-Registration/Decal in Vehicle <br /> 0 0 14 CCR§18459-Responsible Entities Complying with Manifesting Requirements Date Ffl <br /> 0 0 14 CCR§18459.1 -Tire Program ID Number from CalRecycle N <br /> 0 0 14 CCR§18459.2.1 -Submittal of Comprehensive Trip Logs within 90 days (Required for NOV or EXT) N <br /> a <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 /> 0 0 14 CCR§18461 -Manifest System Requirements for Waste Tire End-Use Facilities W <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:§ <br /> Comments �� A� 1j i ! z 15 j 6412 A Ind +011 <br /> ; <br /> f\�ny�al �y-'►5 d J 6n.le t 4. U"LLaerr) — <br /> 1� ` SiLG 1S 'A %C5;;utg1 t 4A4 6uCA L. P�l�l� <br /> At'- (131'p, <br /> ct <br /> Inspection Form Included: 0 ;�jr�[ 60 <br /> Comments Included: 0 <br /> sins I r Phone Number In ctor's Signature Phone Number <br /> INSTRUCTIONS ON 3ACK I Correct: Incorrect: XAMPLE 1 2 3 62081 <br /> E <br /> ■ White Copy:CalRecycle Yellow Copy:Operator Pink Copy:LFA <br />