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Waste Tire Survey & Inspection Report Inspection Report Number <br /> CalRecycle State of California _ <br /> CalRecycle 181(Rev.10/10) <br /> Survey Form Page 1 I1 - 1210471 <br /> Dept.of Resources Recycling and Recovery(CalRecycle) <br /> Part A-Survey BLU_ E OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- , � � � � � � _ � � Inspection Type(Fill one) <br /> p Q Q <br /> Site Suffix: Routine Re-inspection Referral Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier: S h e)�J-0 al. ,� Cu7/�1� 1-n1� Q CHP Q CalRecycle Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name �+ Inspected By Inspector <br /> Co ��' c.o � � �3� � l <br /> Physical Address 3 - CScc��Tv <br /> Inspection Date ( _ 3 <br /> Time In �u Time Out <br /> Business Rep 1, Title M / l� O AM O AM <br /> 3 e PM 3 <br /> 3 v 0 PM <br /> Operational Status Tire Type Business Role Storage Type <br /> Tire Count (Whole/PTE) �-7 (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> / 0 Active ® Passenger ® Generator Q Outdoor <br /> O Q Closed Q Altered <br /> GPS Latitude Q Hauler ® 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 /> ® 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 /> ® 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 /> Q Q PRC§42956-Registration/Decal in Vehicle <br /> Q Q 14 CCR§18459-Responsible Entities Complying with Manifesting Requirements Date <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 EX7) N <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 /> Q Q 14 CCR§18461 -Manifest System Requirements for Waste Tire End-Use Facilities W <br /> Q Q 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators ®In Compliance-No Violations o <br /> Q 1 Q Other:§ <br /> z <br /> Comments <br /> ejm�� ) ,nINA i4101-IQ 1_2 %, N <br /> 0 UI A 1:1:1 al INU <br /> - <br /> '1)t CfCfe 1_ os, Cz�>t- <br /> Inspection Form Included: Q E2o <br /> � _,Comments Included: ® L, V79 <br /> 'sBusiness Rep's Signature Phone Number Insp tor'sSignatu Phone Number <br /> INSTRUCTIONS ON BACK Correct:0 Incorrect: X0 A E X A P L 1 2 3 62081 <br /> White Copy:CalRecycle Yellow Copy:Operator Pink Cop VE <br />