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Waste Tire Survey & Inspection Report Inspection Report Number ■ <br /> State of California <br /> CalRecycle — <br /> CalRecycle 181(Rev.10/10) Survey Form - Page 1 I1 1244909 <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 Type(Fill one) <br /> Site Suffix: • Routine 0 Re-inspection 0 Referral 0 Observation <br /> LocalIf Referral,choose referral type(Fill one) <br /> I <br /> Identifier: so'n lox �I^ O V�,�� 0 CHP 0 CalRecycle 0 Complaint 0 Educational Visit 0 Other <br /> Business or Facility Name 1 <br /> Cy�]L, Inspected By Inspector <br /> c,olt4n 31�Ic. Numb e.r� In r__ <br /> Physical Address 3 1 G - <br /> 1 0 1 GSGo TTo <br /> 333 s- Air P Uri l��, <br /> Inspection Date � / �„ 1 � � 'S <br /> GA <br /> Time In Time Out <br /> Business Re 2 0 AM® 1 ID AM <br /> (� p����� Title� �'� � � J lJ O PM I I �, � <br /> 17b� N o ge n 1O �j C1vP Fvrcn O PM <br /> Operational Status Tire Type Business Role Storage Type <br /> Tire Count(Whole/PTE) L r1 (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> d 0 Active ® Passenger ® Generator 41 Outdoor <br /> 0 Closed 0 Altered <br /> GPS Latitude 0 Hauler ® Indoor <br /> 0 0 Inactive 0 Truck <br /> Longitude – 0 Planned 0 OTR 0 End-Use (9 Container <br /> gr�(Tv <br /> Business Type(Fill all that apply) ( <br /> Awk <br /> 0 New Tire Dealer 0 Auto Repair • 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 Notice Of Violation 0 Extension <br /> O O <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 /> 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 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 /> Q Q Other:§ <br /> Comments �bJ, n N <br /> No 0 f 6j_j.L,,j (4 ou)p corn, <br /> Inspection Form Included: 0 ` <br /> Comments Included:.® <br /> - F `—'P – `0)�b 6 6)/- <br /> usiness Rep's Signature Phone Number rIns tor's Signature Phone Number <br /> �-�( <br /> INSTRUCTIONS ON BACK [Correct:0 Incorrect: X � NJ EXAMPLE 2 3 62081 <br /> . White Copy:CalRecycle Yellow Copy:Operator Pink Cop :L © 0 <br />