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Waste Tire SL rey & Inspection Repor Inspection Report Number ■ <br /> cle State of California <br /> CalRecycle — <br /> Y CalRecycle 181(Rev.10/10) Survey Form - Page 1 I1 1242393 <br /> Dept.of Resources Recycling and Recovery(CalRecycle) <br /> Part A- Survey BLUE OR BLACK INK PEN <br /> Business Profile inspection Details <br /> TPID- ' 'A (D <br /> � © 1 Inspection Type(Fill one) <br /> Site Suffix: '*Routine Q Re-inspection Q Referral Q Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier: Satyr, V\h `.UUttti Q CHP Q CalRecycle Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name Inspected By Inspector <br /> s-'CLe,1 �ca�sQac�al:oyv�ew.s�c,.c 'fl%'�%Iz -3 � _ 1 O N1 A1-`jU <br /> Physical Address <br /> Inspection Date V 3 d I <br /> 11 Time In Time Out <br /> Business Rep Title r 1 1 O S All� PM � 2 © � � PM <br /> 0111 <br /> CS Q cacta� l <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 /> O � Active Q P�S�ger Q ���r Q �/ r <br /> GPS Latitude Closed Q Altered Q <br /> O Q Inactive Q Truck Hauler Q Indoor <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 FA I 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 EXE 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 Q 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators <br /> In Compliance-No Violations o <br /> Q Q Other:§ <br /> Comments �A-�n_-S_cx__. NIN fNt�%N$ &OC � CM <br /> Kit <br /> Inspection Form Included: Q r, a <br /> l 2p ^�30 <br /> Comments Included: <br /> Business Rep's Sig ature Phone Number Inspe tor's Signature Phone Number <br /> INSTRUCTIONS ON BACK I Correct: Incorrect: ve g EXAMPLE 1 2 3 62081 <br /> ■ White Copy:CalRecycle Yellow Copy:Operator Pink Copy:LEA <br />