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Waste Tire Survey & Inspection Report- Inspection Report Number <br /> State of California <br /> CalRecycle CalRecycle 181(Rev.10/10) 11 - <br /> - 1230371 <br /> Dept of Resources Recycling and Recovery(CalRecycle) <br /> Survey Form Page 1 BLUE OR BLACK INK PEN <br /> Part A-Survey <br /> Business Profile Inspection Details <br /> TPID- inspection Type(Fill one) <br /> Site Suffix: f Routine 0 Re-inspection 0 Referral 0 Observation <br /> Local c If Referral,choose referral type(Fill one) <br /> Identifier: 0 CHP 0 CalRecycle 0 Complaint 0 Educational Visit 0 Other <br /> Business or Facility Name Inspected By Inspector <br /> Physical Address -3 c1 (3 � M <br /> Inspection Date CA / i <br /> 53fo cl<_Vor\ C Cis 215 Time In Time Out <br /> Business Rep Title 0 & AM AM <br /> ✓ 0 PM J 0 PM <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 /> 16 0 Active 0 Passenger 0 Generator 0 Outdoor <br /> 0 0 Closed 0 Alt <br /> GPS Latitude %jk 0 Pau ller/k ( Indoor)/A' <br /> 0 0 inactive 0 Truck 0 End-Use 0 Container <br /> Longitude 0 Planned 0 OTR <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 FHAULING AND MANIFEST REQUIREMENTS <br /> A 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 /> / m / m <br /> 0 0 14 CCR§18459.1 -Tire Program ID Number from CalRecycle <br /> (Required for NOV or EX7) 6i <br /> 0 0 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 /> 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 <br /> In Compliance-No Violations <br /> 0 0 Other:§ <br /> Comments <br /> A <br /> Ncs \S'N\tt�-V--fts <br /> oopo� <br /> spa <br /> Inspection Form Included: 0 <br /> Comments Included: 0 <br /> c <br /> Business Rep's Signature Phone Number In pe..cir,Signature Phone Number <br /> 62081 <br /> INSTRUCTIONS ON BACK Correct:* incorrect: M A� FE FX A���� <br /> q — <br /> zs� ve I <br /> ■ White Copy:CalRecycle Yellow Copy:Operator Pink Copy:LEA <br />