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Waste Tire lourvey & Inspection Report Inspection Report Number ■ <br /> CalRec cle State of California <br /> J CalRecycle 181(Rev.10/10) Survey Form - Page 1 10/10) 11 - 1210417 <br /> Dept.of Resources Recycling and Recovery(CalRecycle) <br /> Part A-Survey BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- q 3 3o © r Inspection Type(Fill one) <br /> Site Suffix: 0 l ` ® Routine Q Re-inspection Q Referral Q Observation <br /> Local , \ If Referral,choose referral type(Fill one) <br /> Identifier: Sot( V vim' ��u`� Q CHP Q CalRecycle Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name Inspected By Inspector <br /> cm - SAoU�bibn 3 4 eS <br /> � - 1 1 Cv7TD <br /> Physical Address <br /> 33 N. Aj Art , <br /> Inspection Date <br /> OV' 1 Time In Time Out <br /> Business Rep Title 0 AM I0 AM <br /> v ( �4 Teo. 3 O O PM J PM <br /> �' - Operational Status Tire Type Business Role Storage Type <br /> Tire Count(Whole/PTE) T7 5 (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> ' 1 ® Active ® Passenger 0 Generator ® Outdoor <br /> O Q Closed Q Altered <br /> GPS Latitude Q Hauler Q Indoor <br /> O Q Inactive Q Truck <br /> Longitude - Q Planned Q OTR Q End-Use Q Container <br /> Business Type(Fill all that apply) <br /> Q New Tire Dealer Q Auto Repair Q Trucking Fleet 0 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 Q Agriculture Q 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 /> Q Notice Of Violation Q Extension <br /> Q Q <br /> PRC§42951 -Waste Tire Hauler Registration and Transport of Tires <br /> Q Q PRC§42953-Contracts with Registered Waste Tire Haulers. Compliance Deadline <br /> PRC§42956-Registration/Decal in Vehicle <br /> Q Q 14 CCR§18459-Responsible Entities Complying with Manifesting Requirements Date m <br /> Q Q 14 CCR§18459.1 -Tire Program ID Number from CalRecycle <br /> Q Q 14 CCR§18459.2.1 -Submittal of Comprehensive Trip Logs within 90 days (Required for NOV or EXT) N <br /> a <br /> Q Q 14 CCR§18459.3-Retention of Comprehensive Trip Logs for 3 years o <br /> Q Q 14 CCR§18460.2-Manifest System Requirements for Registered Waste Tire Haulers Q Referred/CalRecycle Enforcement <br /> LU <br /> Q Q 14 CCR§18461 -Manifest System Requirements for Waste Tire End-Use Facilities W <br /> Q O 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators ®In Compliance-No Violations o <br /> Q Q Other:§ <br /> a <br /> Comments <br /> Nb �i �iw�mar ter w_n wn. <br /> Inspection Form Included: 0 1 <br /> 7, <br /> Comments Included: ® <br /> B s p's Signature Phone Number Ins tor's Signet re Phone Number <br /> INSTRUCTION BACK Correct: Incorrect: � � EXAM E 1 2 3 62081 <br /> ■ White Copy:CalRecycle Yellow Copy:Operator Pink CoV <br /> ® ■ <br />