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r , <br /> Waste Tire Survey & Inspection Report .Inspection Report Number ■ <br /> CalRecycle State of California <br /> CalRecycle 181(Rev.10/10) Survey Form - Page 1 I1- — 1176390 <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: ` 0 7 0 S Routine Q Re-inspection Q Referral Q Observation <br /> Local ,` -,, If Referral,choose referral type(Fill one) <br /> Identifier: sos\' hex�c�in� -C�.IYV'� Q CHP Q CalRecycle Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name U Inspected By Inspector <br /> ncA� c T, 3 9 - c t 4l rs� Aim <br /> Physical Address <br /> AA <br /> ( �� r p Inspection Date <br /> C ��//}�� g533 Time In Time Out l <br /> L <br /> ✓ <br /> Business Rep Title } ® AM AM <br /> ,,!! \ t k ' d (� Q PM <br /> UCLA saAc & ©wA e,v-- <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 /> r� <br /> Tire Count (Whole/PTE) , Z 5 ® Active ® Passenger ® Generator Q Outdoor <br /> o Q Closed Q Altered <br /> �PS Latitude Q Hauler Q Indoor <br /> Q Inactive Q Truck <br /> Longitude - Q Planned Q OTR End-Use ® Container <br /> Business Type(Fill all that apply) <br /> New Tire Dealer Q Auto Repair Q Trucking Fleet Q Government Q Retreader Q Dismantler Q Tire Derived Fuel <br /> Q Used Tire Dealer O Auto Body Q Car Dealer Q Collection O Crumb Rubber <br /> Q Service Station Q Hauler Q Agriculture Q Shredder Q Other <br /> Part B - Inspection of Waste Tire Dealer, Generator, Hauler and End-Use Facility ENFORCEMENT STATUS <br /> V A HAULING AND MANIFEST REQUIREMENTS _ --. Q Notice Of Violation O Extension <br /> O O PRC§42951 -Waste Tire Hauler Registration and Transport of Tires <br /> O O PRC§42953-Contracts with Registered Waste Tire Haulers. Compliance Deadline <br /> O O PRC§42956-Registration/Decal in Vehicle <br /> O O 14 CCR§18459-Responsible Entities Complying with Manifesting Requirements Date m m N <br /> O O 14 CCR§18459.1 -Tire Program ID Number from CalRecycle (Required for NOV or EXT) <br /> O 0 14 CCR§18459.2.1 -Submittal of Comprehensive Trip Logs within 90 days a <br /> O 0 14 CCR§18459.3-Retention of Comprehensive Trip Logs for 3 years <br /> Q Q Referred/CalRecycle Enforcement <br /> 14 CCR§18460.2-Manifest System Requirements for Registered Waste Tire Haulers ui <br /> w <br /> O O 14 CCR§18461 -Manifest System Requirements for Waste Tire End-Use Facilities - -- - <br /> O O 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators ®In Compliance-No Violations o <br /> 0 0 Other:§ <br /> Comments <br /> S <br /> Inspection Form Included: Q 8 -te6?-T6 7-3 <br /> Comments Included: i Busi ss ep Signature Phone Number n tor's Si lure Phone Number <br /> 62081 <br /> INSTRUCTIONS ON BACK ct:0 Incorrect: E X A M P L E 1 2 3 <br /> White Copy:CalRecycle Yellow Copy:operator Pink Copy:LEA <br /> ■ <br />