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Waste Tire Survey & Inspection Report Inspection Report Number <br /> CalRecycle State of California I 1 - 1230110 <br /> CalRecycle 181(Rev.10/10) Survey Form - Page 1. <br /> Dept of Resources Recycling and Recovery(CalRecycle) BLUE OR BLACK INK PEN <br /> Part A-Survey - <br /> Business Profile Inspection Details <br /> TPID- Inspection Type(Fill one) <br /> Site Suffix: ' ` v Routine 0 Re-inspection 0 Referral 0 Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier. SU,(��o�,/,,��r� `-��i� 0 CHP 0 CalRecycle 0 Complaint 0 Educational Visit 0 Other <br /> Business or Facility Name 1 1 Inspected By Inspector <br /> Physical Address V� Ulf 0 <br /> ` <br /> CA % Inspection Date <br /> ��3 Time In -` Time Out <br /> Business Rep Title O AM <br /> J v 0 AM f <br /> QPM V V Q PM <br /> L <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) <br /> 0 Active O P sen}�ger 0 Generator 0 Outdoor <br /> O • Closed 0 Alred NSA NA <br /> GPS Latitude 0 Hauler 0 Indoor <br /> O 0 Inactive 0 Truck <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 Q 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 k Ik 1we <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 <br /> 0 0 14 CCR§18459.1 -Tire Program ID Number from CalRecycle <br /> 0 0 (Required for NOV or EX7) <br /> 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 /> 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 1 0 1 Other:§ <br /> Comments � `�>4' -l/`N(n,°�a. �-M� --l��-I1W��5 �Uc�'L o►T 1V� <br /> Vol,,.,�,_„��)�lh� ����r�= �O �J�c� �-v-�� OS U►1c..�,5 �r (1�_ ¢rn <br /> QA <br /> Inspection Form Included: Q q l -e/�� kd;�) <br /> LIV O-31 .8 <br /> Comments Included: Q `( ✓( <br /> Business Rep's gnatu Phone Number Ins ctor's Signature Phone Number <br /> 62081 <br /> INSTRUCTIONS ON BACK Correct:is Incorrect: JEJXJA M P L 11213 <br /> ■ White Copy:CalRecycle Yellow Copy:Operator Pink C py <br />