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' Waste Tire Su. vey & Inspection Repork. Inspection Report Number <br /> CalRecycle State of CaliforniaI T 1 _ 1 1 7 6 4 3 <br /> CalRecycle 181(Rev.10/10) Survey Form - Page 1 1 C1 <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 lype(Fill one) <br /> Site Suffix: I cl 6 �9 1 -6 it Routine Q Re-inspection O Referral Q Observation <br /> Local - �" If Referral,choose referral type(Fill one) <br /> Identifier: ��C�c � �V�� c..tjk_^ Q CHP Q CalRecycle Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name 111 Inspected By Inspector <br /> Strx��i.-�vl, <br /> Physical Address! 9 - I c) l A.t 4,n Anil b, <br /> Saul l�-Ur Ce11,+cr CIY KJ <br /> Inspection Date � <br /> 5�c1�1v\ ��5a1l <br /> Time In Time Out <br /> Business Rep Title O PM l 0 PM <br /> 1 ` :0 0 <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 ® Passenger ® Generator ® Outdoor <br /> O Q Closed Q Altered <br /> GPS Latitude 0 Hauler Q Indoor <br /> o Q Inactive Q Truck <br /> Longitude - Q Planned Q OTR O End-Use Q Container <br /> Business Type(Fill all that apply) <br /> New Tire Dealer • Auto Repair Q Trucking Fleet Q Government Q Retreader O Dismantler Q Tire Derived Fuel <br /> Q Used Tire Dealer Q Auto Body ® Car Dealer Q Collection Q Crumb Rubber <br /> Q Service Station Q Hauler Q Agriculture O Shredder Q 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 /> Notice Of Violation Q Extension <br /> 0 O PRC§42951 -Waste Tire Hauler Registration and Transport of Tires <br /> Q O PRC§42953-Contracts with Registered Waste Tire Haulers. Compliance Deadline <br /> PRC§42956-Registration/Decal in Vehicle <br /> 0 O 14 CCR§18459-Responsible Entities Complying with Manifesting Requirements Date <br /> Q O 14 CCR§18459.1 -Tire Program ID Number from CalRecycle <br /> 0 O 14 CCR§18459.2.1 -Submittal of Comprehensive Trip Logs within 90 days (Required for NOV or Exn N <br /> O O 14 CCR§18459.3-Reten#cin 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 /> 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 ®In Compliance- No Violations <br /> O O Other:§ z <br /> Comments <br /> Inspection Form Included: Q <br /> Comments Included: ® <br /> Business me)K Signature Phone Number In pe o 's i nature Phone Number <br /> - - 62081 <br /> INSTRUCTIONS ON BACK Correct: Incorrect: E X AM L E 1 2 3 <br /> ■ White Copy:CalRecycle Yellow Copy:Operator Pink Cop :L © ■ <br />