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*Inspection Report Number <br /> Waste Tire 6urvey & Inspection Rep@ ■ <br /> CalRecycle State of California - 1176383 CalRecycle 181(Rev.10/10) Survey Form - Page 1 I1 117 6 3 8 3 <br /> Dept.of Resources Recycling and Recovery(CalRecycle) <br /> PartA- Survey—__.... BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- I I �j ) ) - O I Inspection Type(Fill one) <br /> Site Suffix: t l "� 0 Routine Q Re-inspection Q Referral Q Observation <br /> Local 1 If Referral,choose referral type(Fill one) <br /> Identifier: s ct n J 0 -I L&t n Co14r) Q CHP Q CalRecycle Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name _I Inspected By Inspector <br /> 'S uk r�. Auh I <br /> Physical Address q I E C4) <br /> 5�o('�40r� � Inspection Date � / l v1 <br /> p l dV Time In Time Out <br /> l <br /> Busineg R \ ����\Sf� TVILet o (Mce'r 6 ,M, 0 AM 0 AM <br /> PM VI S ® PM <br /> �i <br /> -- Operational Status Tire Type Business Role Storage Type <br /> Tire Count (Whole/PTE) 9 (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> 0 Active 10 Passenger Op Generator Q Outdoor <br /> O Q Closed Q Altered <br /> GPS Latitude Q Hauler 0 Indoor <br /> O Q Inactive Q Truck <br /> Longitude - — — Q Planned Q OTR Q End-Use 0 Container <br /> Business Type(Fill all that apply) <br /> ® New Tire Dealer ®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 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 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 / m / 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 EXE n <br /> Q Q 14 CCR§18459.3-Retention of Comprehensive Trip Logs for 3 years <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 is In Compliance-No Violations o <br /> Q Q Other:§ <br /> Comments <br /> u o OCU <br /> Ivo 1UpS b< e4 (ecc u <br /> Inspection Form Included: Q <br /> Comments Included: 0 <br /> Bu_ess ep's ign lure Phone Number Insp�rl'sS ure one Number <br /> INSTRUCTIONS ON BACK Corre t:0 Incorrect: l E X A L 1 2 3 62081 <br /> ■ White Copy:CalRecycle Yellow Copy:Operator Pink C y:L © ■ <br />