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Waste Tire Su. ,iey & Inspection Report Inspection Report Number ■ <br /> CalRecycle State of CaliforniaY CalRecycle 181(Rev.10/10) Survey Form - Page 1 I1 - 1210187 <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 7 S Cj 2 3 3 l 0 Routine Q Re-inspection Q Referral Q Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier: SG-11 70 0.n�v;^ Cb�,��y Q CHP Q CalRecycle Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name " Inspected By Inspector <br /> f\1 6.a-S '1 c) �� v <br /> Physical Address <br /> 5 5 7 L av e - - <br /> Inspection Date -7 / 1 1 / I 3 <br /> Sc�cko� C 9S201 1 <br /> Time In Time Out <br /> Business Rep Title \ 0 AM I ` 5 0 AM <br /> e PM I S ® 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 /> Lli 0 Active 9 Passenger 9 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 /> New Tire Dealer 0 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 <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 a <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 /> 2 <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 Q Other:§ - z <br /> Comment\s��vr���a��. `` �p,`C'C_ <br /> Inspection Form Included: Q UAspe�� <br /> „Comments Included: Ijss Rep's Signature Phone Number or',Signature Phone Number <br /> INSTRUCTIONS ON BACKCorrect: Incorrect: g IEIXIAIMIPILIEI 111213 62081 <br /> ® White Copy:CalRecycle Yellow Copy:Operator Pink Copy:LEA ® ■ <br />