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Waste Tire Survey & Inspection deport "Inspection Report Number <br /> cle State of California <br /> CalRecycle CalRecycle 181(Rev.10110) Survey Form - Page 1 11 1210348 <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: "I 41 Routine 0 Re-inspection 0 Referral 0 Observation <br /> Local ( If Referral,choose referral type(Fill one) <br /> Identifier: S a V1, 'TbCL�V�� W v��y 0 CHP 0 CalRecycle 0 Complaint 0 Educational Visit 0 Other <br /> Business or Facility Name Spoe\-4\V\e-S Inspected By Inspector <br /> Physical Address ! v <br /> C� gs2y� Inspection Date 6 <br /> Time In Time Out <br /> Business Rep Title 0AM 0 AM <br /> I 1 V 0 PM k 2 1 0 PM <br /> �cxykc <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 /> 49 Active 0 Passenger 0 Generator 0 Outdoor <br /> PS `r <br /> Latitude o 0 Closed 0 Altered O Hauler Indoor A <br /> G <br /> 0 0 Inactive 0 Truck <br /> Longitude — 0 Planned ® OTR 0 End-Use 0 Container <br /> Business Type(Fill all that apply) Folic <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 4 Other IRC11l:k C_S /66 h SO e' O <br /> Part B - Inspection of Waste Tire Dealer, Generator, Hauler and End-Use Facility ENFORCEMENT STATUS <br /> V I 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 EXT) 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 w <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 <br /> rQ ��SP <br /> �—M kA N.AM ot.5 <br /> Inspection Form Included: 0 <br /> Comments Included: �3 ,�� e �7�'"`�—!/ 2 <br /> B mess R Signatu Phone Number Insp tor's Signature Phone Number <br /> 62081 <br /> INSTRUCTIONS ON BAC Correct: Incorrect: E X A M P LE 1112 3 <br /> ® White Copy:CalRecycle Yellow Copy:Operator Pink Copy:LEA ® ■ <br />