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Waste Tire Su. ✓ey & Inspection Report Inspection Report Number <br /> CalRecycle State of California I 1 - 1210337 <br /> CalRecycle 181(Rev.10/10) Survey Form - Page 1 <br /> Dept.of Resources Recycling and Recovery(CalRecycle) <br /> Part A-Survey BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- 1 2 � � � � � _ � � Inspection Type(Fill one) <br /> Site Suffix: > 0 Routine 0 Re-inspection 0 Referral 0 Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier: �6p�q v C�V vv 0 CHP 0 CalRecycle 0 Complaint 0 Educational Visit 0 Other <br /> Business or Facility Name Inspected By Inspector <br /> Sa`vdr �r2 S��e - O /�1/�TTv <br /> Physical Address 9 <br /> C� i�2�� Inspection Date <br /> Time In Time Out <br /> Business Rep Title O AM O AM <br /> 0 0 PM J S PM <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 /> a <br /> ' ' 1 0 Active SP Passenger *Generator 0 Outdoor <br /> O 0 Closed 0 Altered <br /> GPS Latitude 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 Dismantler 0 Tire Derived Fuel <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 <br /> 0 0 § - - �Notice Of Violation � 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 /> 00 14 CCR§18459-Responsible Entities Complying with Manifesting Requirements Date Ffl / m / m <br /> 0 0 14 CCR§18459.1 -Tire Program ID Number from CalRecycle a <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 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 /> 0 0 Other:§ <br /> Comments � <br /> ova AANI S c).m-k-2 ck_tn <br /> Inc <br /> Inspection Form Included: 0 ♦ 20�{��/�+_ � <br /> Comments Included: ,� ba <br /> sl es igna a Phone t mb ^ Inspec or's Signature Phone Number <br /> INSTRUCTIONS ON BACK Correct: Incorrect: IEIXIAIMIPILIEI 1112 3 62081 <br /> White Copy:CalRecycle Yellow Copy:Operator Pink Copy:LFA <br />