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............ <br /> Waste Tire Survey & Inspection Report Inspection Report Number ■ <br /> State of California <br /> CalRecycle CalRecycle 181(Rev.10/10) - 1196654 <br /> Dept.of Resources Recycling and Recovery(CalRecycle) Survey Form Page 1 BLUE OR BLACK INK PEN <br /> Part A-Survey <br /> Business Profile Inspection Details <br /> TPID- Inspection Type(Fill one) <br /> Site Suffix: 0 5 9 0 0 0 Routine 0 Re-inspection 0 Referral 0 Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier: Sam Tou C0113 0 CHIP 0 CalRecycle 0 Complaint 0 Educational Visit 0 Other <br /> "., <br /> Business or Facility Name Inspected By Inspector <br /> Physical Address <br /> ?.C.sc) <br /> Inspection Date <br /> Time In Time Out <br /> Business Rep Title 0 AM 0 AM <br /> 0 0 OPM PM <br /> lav Com- 0 Wv�e <br /> Operational Status Tire Type Business Role Storage Type <br /> (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that Type <br /> Tire Count(Whole/PTE) 0 out oor <br /> 0 Active 0 Passenger 4b Generator 0 Outdoor <br /> 0 0 Closed 0 Altered ..... <br /> GPS Latitude 0 Hauler 0 indoor <br /> 0 0 inactive 0 Truck <br /> Longitude 0 Planned 4j OTR 0 End-Use 0 Container <br /> Business Type(Fill all that apply) 0 Dismantler 0 Tire Derived Fuel <br /> _�New�TireDealero Auto Repair 0 Trucking Fleet 0 Government 0 Retreader <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 V!L-A� <br /> MVIX — <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 <br /> m NM <br /> N�t <br /> 0 0 14 CCR§18459.1 -Tire Program ID Number from CalRecycle �p <br /> Lo <br /> (Required for NOV or EXT) <br /> 0 0 14 CCR§18459.2.1 -Submittal of Comprehensive Trip Logs within 90 days <br /> I <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 /> 2 <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 •in compliance-No Violations <br /> 010 Other:§ <br /> Comments <br /> Inspection Form Included: 0 797 �;2JT- qor-OW 3 2ol-`469-3299 <br /> Comments Included: 0 Business Rep's Signature Phone Number Anspe tor's Signature Phone Number <br /> 62081 <br /> INSTRUCTIONS ON BACK Correct:* incorrect: E X A M P L E <br /> - zs� W <br /> MWhite Copy:CalRecycle Yellow Copy:Operator Pink Copy:LEA M <br />