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........................ ... ------ <br /> Waste Tire Survey & Inspection Report Inspection Report Number <br /> State of California - -1176839 <br /> CalRecycle CalRecycle 181(Rev.10/10) 11 <br /> Dept.of Resources Recycling and Recovery(CalRecycle) BLUE <br /> Form Page 1 BLUE OR BLACK INK PEN <br /> PartA- Survey <br /> Business Profile inspection Details <br /> TPID- inspection Type(Fill one) <br /> Site Suffix: '-4 6 I&Routine 0 Re-ins 0 Observation <br /> 0 <br /> Local If Referral,choose refer i ne)OP <br /> Identifier: ccx_cf.�LA� 0 CHP 0 CalR"y'l "t u'y nal Visit 0 Other <br /> Business or Facility Name Inspected By Inspector <br /> 1k)bar lei <br /> -<s <br /> PhysM.sdress <br /> Inspection Date C) Z-1 <br /> eA Time In Time Out <br /> Business Rep Title 0 AM 0 AM <br /> I : 'g C) (b PM PM <br /> Vt IN&- <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) 90 0 Active 0 Passenger 9 Generator 0 Outdoor <br /> GPS Latitude 0 0 Closed 0 Altered 0 Hauler 0 indoor <br /> 0 0 inactive 0 Truck ® End-use 0 container <br /> Longitude 0 Planned 0 OTR <br /> Business Type(Fill all that apply) <br /> I* 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 A HAULING AND MANIFEST REQUIREMENTS 0 Notice Of Violation 0 Extension <br /> 10 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 N <br /> 0 0 14 CCR§18459.1 -Tire Program ID Number from CalRecycle <br /> (Required for NOV or EXT)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 EnforcementLu <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 /> 0 0 Other:§ <br /> Comments <br /> Inspection Form Included <br /> Comments Included:0 ct r' i a re Phone Number <br /> urines ep's Signat Phone Number I S ect 62081 <br /> INSTRUCTIONS ON BACK Correct:16 incorrect: E I X A IM 11 1213�11 <br /> 1 _IX <br /> ■ White Copy:CalRecycle Yellow Copy:Operator Pink lCopy: <br />