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Waste Tire Survey & Inspection Report Inspection Report Number ■ <br /> State of California <br /> Cal Recycle CalRecycle 181(Rev.10/10) c Page 1— 11 - 1177778 <br /> Dept of Resources Recycling and Recovery(Ca]Re(CalRecycle) <br /> Form <br /> Part A-Survey BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- Inspection Type(Fill one) <br /> Site Suffix: 0 q 9 c) *Routine 0 Re-inspection 0 Referral 0 Observation <br /> LocalIf Referral,choose referral type(Fill one) <br /> Identifier: Yl 0 CHP 0 CalRecycle 0 Complaint 0 Educational Visit 0 Other <br /> -Cb <br /> Business or Facility Name Inspected By Inspector <br /> - -T�ry--) <br /> PhysicaqAddress <br /> Inspection Date <br /> Time In Time Out <br /> Business Rep Title 10 AM AM <br /> / 0 99 0 PM 0 0 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 /> 0 Active 0 Passenger ® Generator 0 Outdoor <br /> O 0 Closed 0 Altered <br /> GPS Latitude 0 Hauler 0 indoor <br /> 0 0 inactive 9 Truck <br /> Longitude 0 Planned 0 OTR 0 End-Use 0 Container <br /> Business Type(Fill all that apply) <br /> 0 New Tire Dealer 0 Auto Repair 6—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 AI 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) 64a <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 /> 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 in Compliance-No Violations <br /> 0 0 Other:§ <br /> Comments <br /> _k <br /> Inspection Form Included: 0 <br /> Comments Included: V ErusiA Rep' ignature Phone Number sp tor re Phone Number <br /> INSTRUCTIONS ON BACK Correct:0 incorrect: E A E 1 2 3 <br /> 62081 <br /> ■ White Copy:CalRecycle Yellow Copy:Operator Pink Co <br /> V_ © ■ <br />