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X <br /> Waste Tre Survey & Inspection Repoinspection Report Number <br /> CalRecycle State of California <br /> CalRecycle 181(Rev.10/10) 11 - 1242243 <br /> Dept.of Resources Recycling and Recovery(CalRecycle) Survey Form - Page I BLUE OR BLACK INK PEN <br /> Part A-Survey <br /> Business Profile Inspection Details <br /> TPID- _7 k, Inspection Type(Fill one) <br /> Site Suffix: 4) Routine 0 Re-inspection 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 /> 9 (7- S 1: <br /> Physical Address <br /> Inspection Date c) <br /> Time In Time Out <br /> Business Rep TitleWAM 0 AM <br /> 0 0 PM PM <br /> CL c-'r\ C 'eevjeq- <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 /> Tire Count (Whole/PTE) <br /> 0 Active 0 Passenger 40 Generator 0 Outdoor <br /> 0 0 closed 0 Altered <br /> GPS Latitude 0 Hauler 0 indoor <br /> O 0 inactive 0 Truck <br /> 0 End-Use 9 Container <br /> Longitude 0 Planned OTR <br /> Business Type(Fill all that apply) 1 - <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 II&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 0 Notice Of Violation 0 Extension <br /> 0 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 m / m / m <br /> 0 0 14 CCR§18459.1 -Tire Program ID Number from CalRecycle (Required for NOV or EXT) <br /> 0 0 14 CCR§18459.2.1 -Submittal of Comprehensive Trip Logs within 90 days <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 /> Lu <br /> 0 0 14 CCR§18461 -Manifest System Requirements for Waste Tire End-Use Facilities <br /> 0 0 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators I&In Compliance-No Violations <br /> 0 0 Other:§ <br /> Comments y,_e (5 V-k <br /> cn_N_Cck_ <br /> Inspection FormI nc�uded: 0 <br /> cJC� <br /> trl <br /> Comments Included: • <br /> 40 4Bus11ne;R!epW':s Signature Phone Number Inspector's Signature Phone Number <br /> 62081 <br /> INSTRUCTIONS ON BACK [Correct:0 incorrect, X=J� q I EXAMI P L E 1 2 3 <br /> ■ White Copy:CalRecycle Yellow Copy:Operator Pink Copy:LEA ® ■ <br />