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i <br /> Waste Tire S%.. ojey & Inspection Report Inspection Report Number <br /> CalRecycle State of California I 1 - 1210507 <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- q Inspection Type(Fill one) <br /> Site Suffix: I ' O I ® Routine 0 Re-inspection 0 Referral 0 Observation <br /> LocalC If Referral,choose referral type(Fill one) <br /> Identifier: �o(1 JD�lgW r) CU 0 CHP 0 CalRecycle 0 Complaint 0 Educational Visit 0 Other <br /> BusinessorFacility Name I1 Inspected By Inspector <br /> T1 I0-- cS wr(2-I �I 0 S _ 1 <br /> Physical Address C) ti TT <br /> Sva (_4�'0 Inspection Date <br /> �e c P SSZos <br /> Time In Time Out <br /> Business Rep Title5 O AM O AM <br /> i ® PM S is PM <br /> L-ui 5 V1\1 J 0 pb o�neT <br /> Operational Status Tire Type Business Role Storage Type <br /> Tire Count (Whole/PTE) Q O (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> Active * Passenger * Generator ® Outdoor <br /> O 0 Closed 0 Altered <br /> GPS Latitude 0 Hauler 0 Indoor <br /> O 0 Inactive 0 Truck <br /> Longitude - 0 Planned 0 OTR 0 End-Use 0 Container <br /> Business Type(Fill all that apply) <br /> Al New Tire Dealer ® 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 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 /> PRC§42956-Registration/Decal in Vehicle <br /> 0 0 14 CCR§18459-Responsible Entities Complying with Manifesting Requirements Date 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 /> 2 <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 in n ' r Q N <br /> 11,, <br /> - ��{ In1 (Aims <br /> �IltQr� <br /> Inspection Form Included: 0 <br /> Comments Included: OCr7)�/-�-07� — 'lY W1 —31)9 <br /> Business Rep's Signature Phone Number Inspe t is Signature Phone Number <br /> INSTRUCTIONS ON BACK Correct:0 Incorrect: 07q7l EXAM L E 1 2 H3 62081 <br /> ■ White Copy:CalRecycle Yellow Copy:Operator Pink Co y: ® ■ <br />