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Waste Tire Su. Bey & Inspection Report Inspection Report Number <br /> Cal Rec cle State of California <br /> Y CalRecycle 181(Rev.10/10) Survey Form - Page 1 11 - 1177771 <br /> Dept.of Resources Recycling and Recovery(calRecycle) <br /> Part A-Survey BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- Inspection Type(Fill one) <br /> Site Suffix: i 3 (;� OL LL _3 d 1 ® Routine Q Re-inspection Q Referral Q Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier: Q CHP Q CalRecycle O Complaint Q Educational Visit Q Other <br /> Business or Facility Name Inspected By Inspector <br /> 'V_ - S`�0.JSS -S�l _ f (' <br /> Physical Address ( j>Z/� <br /> Inspection Date / O <br /> Time In Time Out l J <br /> Business Rep Titlet j 0 AM i 0 AM <br /> 1 ® PM ` ® 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 /> ® Active Q Passenger ® Generator Q Outdoor <br /> Q Closed O Altered <br /> GPS Latitude Q Hauler e Indoor <br /> 0 Q Inactive Q Truck <br /> Longitude - O Planned ® OTR O End-Use O Container <br /> Business Type(Fill all that apply) <br /> Q New Tire Dealer Q Auto Repair Q Trucking Fleet Q Government Q Retreader Q Dismantler Q Tire Derived Fuel <br /> Q Used Tire Dealer Q Auto Body Q Car Dealer Q Collection Q Crumb Rubber <br /> Q Service Station Q Hauler O Agriculture Q Shredder ® Other �� G1,✓U <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 m / m / m N <br /> O O 14 CCR§18459.1 -Tire Program ID Number from CalRecycle zi� <br /> 0 O 14 CCR§18459.2.1 -Submittal of Comprehensive Trip Logs within 90 days (Required for NOV or EXE N <br /> O Q 14 CCR§18459.3-Retention of Comprehensive Trip Logs for 3 years <br /> O O 14 CCR§18460.2-Manifest System Requirements for Registered Waste Tire Haulers Q Referred/CalRecycle Enforcement <br /> W <br /> Q O 14 CCR§18461 -Manifest System Requirements for Waste Tire End-Use Facilities W <br /> O O 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators ®In Compliance-No Violations <br /> O O Other:§ <br /> z <br /> Comments <br /> CfJl1't <br /> Inspection Form Included: Q <br /> Comments Included: ()`1�•�C_ � �/ -�Yh�'-P�? <br /> Business ep's Signature Phone Number Insfec is gnature Phone Number <br /> 62081 <br /> INSTRUCTIONS ON BACK Correct: Incorrect: E A E 1 1112 3 <br /> ■ White Copy:CalRecycle Yellow Copy:Operator Pink Co : ® ■ <br />