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Waste Tire Survey & Inspection Report Inspection Report Number <br /> Cal Rec cle State of California <br /> Y CalRecycle 181(Rev.10/10) Survey Form - Page 1 1 - 1226659 <br /> Dept.of Resources Recycling and Recovery(CalRecycle) <br /> BLUE OR BLACK INK PEN <br /> Part A-Survey <br /> Business Profile Inspection Details - <br /> TPID- 4 Q - /� Inspection Type(Fill one) <br /> Site Suffix: 9 1 V I 0 Routine Q Re-inspection Q Referral Q Observation <br /> LocalIf Referral,choose referral type(Fill one) <br /> Identifier: SU O U ri^ Cnu 0 CHP Q CalRecycle 0 Complaint 0 Educational Visit 0 Other <br /> Business or Facility Name Inspected By Inspector <br /> TkA�A Q0154_A6 _��)(:-. ES <br /> Physical Address <br /> Ose,n ) <br /> Inspection Date <br /> Time In Time Out 1 <br /> Business Rep Title � : 0 AM ' D 0 AM <br /> I O PM ® PM <br /> --- -- - --�- Operational Status Tire Type Business Role Storage Type <br /> Tire Count (Whole/PTE) <br /> (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> � � � a- 5 <br /> ® Active O Passenger ® Generator ® Outdoor <br /> 0 0 Closed Q Altered <br /> GPS Latitude ® Hauler O Indoor <br /> O Q Inactive ® Truck <br /> Longitude - Q Planned 0 OTR O End-Use ® Container <br /> Business Type(Fill all that apply) <br /> ® New Tire Dealer 0 Auto Repair ® Trucking Fleet 0 Government 0 Retreader O Dismantler O Tire Derived Fuel <br /> ® Used Tire Dealer 0 Auto Body Q Car Dealer 0 Collection O Crumb Rubber <br /> 0 Service Station 0 Hauler O 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 /> Q Notice Of Violation � Extension <br /> O O <br /> PRC§42951 -Waste Tire Hauler Registration and Transport of Tires <br /> O O PRC§42953-Contracts with Registered Waste Tire Haulers. Compliance Deadline <br /> O O PRC§42956-Registration/Decal in Vehicle <br /> O O 14 CCR§18459-Responsible Entities Complying with Manifesting Requirements Date <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 E)C7) N <br /> a <br /> O O 14 CCR§18459.3-Retention of Comprehensive Trip Logs for 3 years o <br /> O O 14 CCR§18460.2-Manifest System Requirements for Registered Waste Tire Haulers Q Referred/CalRecycle Enforcement <br /> W <br /> O O 14 CCR§18461 -Manifest System Requirements for Waste Tire End-Use Facilities <br /> O O 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators (f In Compliance- No Violations o <br /> 0 Other:§ z <br /> -= <br /> Comments . rte S t �'c. 0 I ` <br /> NOy'104W IPIs bJ !i►/LaS d�r Gyf)W( <br /> Inspection Form Included: 6 <br /> Comments Included: ® �� ((ff ll ( ( d�fl <br /> Business Rep s Signature Phone Number Inspe is Signature Phone Number <br /> INSTRUCTIONS ON BACK Correct:0 Incorrect: � Ve62081 <br /> � E X A M 1 2 3 <br /> ■ White Copy:CalRecycle Yellow Copy:Operator Pink Cop © ■ <br />