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Waste Tire Arve & Inspection Re of Inspection Report Number <br /> CalRec cle State of California — <br /> Y CalRecycle 181(Rev.10/10) Survey Form - Page 1 I1 1242550 <br /> Dept.of Resources Recycling and Recovery(CalRecycle) <br /> Part A-Survey BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- I OI Inspection Type(Fill one <br /> Site Suffix: O 5 nRoutine 0Re-inspection Q Referral Q <br /> Observation <br /> Local IIf Referral,choose referral type(Fill one) <br /> Identifier: 7SC." 70" u.r� 411 Q CHP Q CalRecycle Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name Inspected By Inspector <br /> Physical Address '7S V G<" to V <br /> kAo is',' F, - A0 A f�N I, <br /> 4A Inspection Date <br /> 0�0-1 <br /> C �►Sz�s <br /> Time In Time Out <br /> Business Rep Title C O AM 0 AM <br /> • J ® PM �• , Q 40PM <br /> CIA � o G� c:� M ('. <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 /> 40 Active ® Passenger 0 Generator I®Outdoor <br /> O Q Closed Q Altered <br /> GPS Latitude Q Hauler Q Indoor <br /> O Q Inactive O 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 0 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 /> Q Q 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 y <br /> Q Q 14 CCR§18459.2.1 -Submittal of Comprehensive Trip Logs within 90 days (Required for NOV or EXT) <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 O In Compliance-No Violations o <br /> Q Q Other:§ <br /> Comments 0 11 I N <br /> N J 4 c.3ncern <br /> Inspection Form Included: Q <br /> Comments Included:® 2oM_` q Q-g 3-7 o m w- —3) O <br /> Business Rep's Signature Phone Number Ins a tor's Signature Phone Number <br /> INSTRUCTIONS ON BACK Correct: Incorrect: E X A P L 1 2 3 62081 <br /> White Copy:CalRecycle Yellow Copy:Operator Pink Cop L <br />