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Waste Tire Survey & Inspection Report Inspection Report Number <br /> State of California <br /> CalRecycle CalRecycle 181(Rev.10/10) 1 11 - <br /> Su1255931 <br /> Dept of Resources Recycling and Recovery(CalRecycle) <br /> rvey Form - Page BLUE OR BLACK INK PEN <br /> Part A-Survey <br /> Business Profile Inspection Details <br /> TPID- Inspection Type(Fill one) <br /> Site Suffix: i 1 I l a I 0 Routine 0 Re-inspection 0 Referral 0 Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier: Sa r-% 0 CcLk� x0 CHP 0 CalRecycle 0 Complaint 0 Educational Visit 0 Other <br /> Business or Facility Name l Inspected By Inspector <br /> 1)C " Wit 5 _P S-be y- -:7D <br /> Physical Address 5A+jv_v&L., Pialu <br /> UCC) 0 . <br /> Inspection Date ( 7- t b L <br /> Time In Time Out <br /> Business Rep Title 0 0 AM 4 0 AM <br /> -1 0 PM WPM <br /> Operational Status Tire Type Business Role Storage Type <br /> Tire Count(Whole/PTE) 5— Z__ (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> 0 Active 0 Passenger 40 Generator 0 Outdoor <br /> GPS Latitude 0 0 Closed 0 Altered 0 Hauler 0 indoor <br /> Longitude 0 0 Inactive ® Truck 0 End-Use 0 Container <br /> 0 Planned 0 OTR <br /> Business Type(Fill all that apply) <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 0 Other <br /> Part B - Inspection of Waste Tire Dealer, Generator, Hauler and End-Use Facility ENFORCEMENT STATUS <br /> V I A I 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 <br /> 0 0 14 CCR§18459.2.1 -Submittal of Comprehensive Trip Logs within 90 days (Required for NOV or EXT) <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 /> W <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 <br /> 40 in compliance-No Violations <br /> 0 0 Other:§ <br /> Comments R44 H 12 iL14" <br /> cly_► <br /> Inspection Form Included: 0CIO, <br /> Comments Included: * 1h a,-c <br /> Business Rep's Signature Phone Number Inspector's Signature Phone Number <br /> INSTRUCTIONS ON BACK I Correct:* Incorrect: ?V lz� 62081 <br /> ■ zs� WV IIEIXIAIMIPILI <br /> White Copy:CalRecycle Yellow Copy:Operator Pink Copy:LEA ® ■ <br />