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............. -------------- ....... ------- <br /> ---------------- ........ <br /> Waste Tire Survey & Inspection Report Inspection Report Number <br /> CalRecycleState of California <br /> CalRecycle 181(Rev.10110) 11 - 1210487 <br /> Dept.of Resources Recycling and Recovery(Cal S1 <br /> Form - Page 1 <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 <br /> 0 Referral 0 Observation <br /> Local 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 /> 13\Et� T�re_PhysAddress <br /> 13'5 G, to A'� Avt <br /> -LA 0 Inspection Date. <br /> CA <br /> Time In Time Out <br /> Business Rep Title 10 AM 1 e AM <br /> 0 PM 0 PM <br /> Uoo "0_ 1AaAWr^ <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 /> 0 Active * Passenger 0 Generator 0 Outdoor <br /> GPS Latitude 0 0 Closed 0 Altered 0 Hauler 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 /> New Tire Dealer 0 Auto Repair 0 Trucking Fleet 0 Government 0 Retreader 0 Tire Derived Fuel <br /> L, <br /> 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 Notice'Of Violation 0 Extension <br /> 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 <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 EXT) N <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 LU <br /> 0 0 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators 0 In Compliance-No Violations <br /> 0 0 Other:§ <br /> Comments 'N. <br /> N <br /> Wulf Oike4k�- <br /> Inspection Form Included: 0 <br /> - 0' <br /> Comments Included- <br /> 1 4�th Phone Number <br /> �j Busin Rep's Signature Phone Number �1�nspe�,'s Sig�natur, <br /> INSTRUCTIONS ON BACK I Correct:® incorrect: X JLJ 1112 3 62081 <br /> White Copy:CalRecycle Yellow Copy:Operator Pink Copy:LEA <br />