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Waste Tire S.,.,vey & Inspection Repor, Inspection Report Number <br /> CalRecycle State of California I 1 - 1226332 <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- i 1` 1 0 _ Inspection Type(Fill one) <br /> Site Suffix: 0 Routine 0 Re-inspection 0 Referral 0 Observation <br /> Local �' L If Referral,choose referral type(Fill one) <br /> Identifier: so,'( J 0 IMr\ �u�7 0 CHP 0 CalRecycle 0 Complaint 0 Educational Visit 0 Other <br /> Business or Facility Name 11 Inspected By Inspector <br /> 5 C`(\U3 0_(�) s �1 1e_ (�c(v 1 (ems <br /> Physical Address I d I Cj W6 <br /> Xi s 2 n �,v, ( ti w1 eel 1Y <br /> 0rCA G 533'1 Inspection Date � � O 3 <br /> �(1 U �«., <br /> Time In Time Out <br /> Business Rep 1 1 Title � 0 5 0 AM 0 AM <br /> 3 3 5 <br /> PM ® PM <br /> Operational Status Tire Type Business Role i Storage Type <br /> Tire Count(Whole/PTE) (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> ' 41 Active 0 Passenger 9 Generator 0 Outdoor <br /> D 0 Closed 0 Altered N/A <br /> GPS Latitude 0 Hauler 0 Indool <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 /> 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 ® Other (b f n Sq�( <br /> Part B - Inspection of Waste Tire Dealer, Generator, Hauler and End-Use Facility ENFORCEMENT STATUS <br /> V A HAULING AND MANIFEST REQUIREMENTS <br /> 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 EXE <br /> 0 0 14 CCR§18459.3-Retention of Comprehensive Trip Logs for 3 years <br /> 0 <br /> 0 0 14 CCR§18460.2-Manifest System Requirements for Registered Waste Tire Haulers 0 Referred/CalRecycle Enforcement <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 0 In Compliance-No Violations o <br /> 0 0 Other:§ I I <br /> Comments <br /> k t.Jn t-J( ' <br /> Inspection Form�nc <br /> ncluded: 0 11r h <br /> Comments luded: -- -- - - --- �— <br /> Business Rep's Signature Phone Number Insp c or's Signature Phone Number <br /> INSTRUCTIONS ON BACK Correct:0 Incorrect: ? E X A L 1 2 3 62081 <br /> ■ White Copy:CalRecycle Yellow Copy:Operator Pink C A © ■ <br />