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Waste Tireey & Inspection Repftnspection Report Number ■ <br /> CalRec cle State of California <br /> Y CalRecycle 181(Rev.10/10) Survey Form - Page 1 I1 -1176453 <br /> Dept.of Resources Recycling and Recovery(CalRecycle) <br /> Part A-Survey BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- t Inspection Type(Fill one) <br /> Site Suffix: l O O 1 0 Routine 0 Re-inspection 0 Referral 0 Observation <br /> Local �1 ^ '^; L If Referral,choose referral type(Fill one) <br /> Identifier: 1 ,v\ b vl {�l 0 CHP 0 CalRecycle 0 Complaint 0 Educational Visit 0 Other <br /> Business or Facility Name Inspected By Inspector <br /> Physical Addr &,f) E5y ko <br /> Mzic Art N1W �S , <br /> (0, S� / Inspection Date `7 / / I <br /> Time In Time Out 111 <br /> Business Rep Title ` 1 1 10 AM ' i ® AM <br /> ` 1 O QPM j 0 P <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 /> /ll_/ 0 Active 0 Pass n 1�er 0 Generator 0 Outdoor <br /> Closed 0 Alter/17� NJA <br /> GPS Latitude 0 Haulier 4 0 Indoor <br /> 0 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 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 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 <br /> 0 0 0 Notice Of Violation 0 Extension <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 m / m / m <br /> 0 0 14 CCR§18459.1 -Tire Program ID Number from CalRecycle <br /> 0 0 14 CCR§18459.2.1 -Submittal of Comprehensive Trip Logs within 90 days (Required for NOV or EXE N <br /> 0 0 14 CCR§18459.3-Retention of Comprehensive Trip Logs for 3 years <br /> 0 <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 u, <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�l�tTl ` l n. U lc. 1 (��� In <br /> is' <br /> loin 5mut-A r i'r �r <br /> �vo� �P -01 <br /> A4 <br /> A4 <br /> Inspection Form�nc <br /> ncluded: 0 <br /> Comments luded: <br /> 0 Business Rep's Signature PhoneNumber Insp or's Signature Phone Number <br /> - — - -- - -- <br /> 62081 <br /> INSTRUCTIONS ON BACK Correct: Incorrect: E X A L 1 2 3 <br /> ■ White Copy:CalRecycle Yellow Copy:Operator Pink C y: A © ■ <br />