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Waste Tire Sufley & Inspection Reportonspection Report Number ■ <br /> CalRecycle State of California _ I 1 1230162 <br /> CalRecycle 181(Rev.10/10) Survey Form Page 1 <br /> Dept of Resources Recycling and Recovery(CalRecycle) <br /> Survey <br /> BLACK INK PEN <br /> Part A- Survey <br /> Business Profile Inspection Details <br /> TPID- Inspection Type(Fill one) <br /> Site Suffix: c 40 Routine Q Re-inspection Q Referral Q Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier: SCS M J d 0.q�L Vl �1 ®� Q CHP Q CalRecycle Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name Inspected By Inspector <br /> Physical Address <br /> 63 Inspection Date � A�, � z <br /> S$��VG�� � Time In �J Time Out <br /> Title 0 AM : ? - 0 AM <br /> Business Repp 5 0 PM L ®PM <br /> Pa-"' ' Operational Status Tire Type Business Role Storage Type <br /> Tire Count (Whole <br /> 6 (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> 40 Active IV Passenger . Generator Q Outdoor <br /> O Q Closed ® Altered <br /> GPS Latitude Q Hauler Q Indoor <br /> O Q Inactive ® Truck <br /> Longitude - ® OTR Q End-Use • Container <br /> Q Planned <br /> Business Type(Fill all that apply) <br /> Q 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 /> Q Service Station Q Hauler Q Agriculture Q Shredder • 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 <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 EXT) 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 /> w <br /> w <br /> Q Q 14 CCR§18461 -Manifest System Requirements for Waste Tire End-Use Facilities <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:§ <br /> Comments <br /> � t, �a,c�L c� co p� Cea S Gan C°ei'Vl <br /> Inspection Form Included: Q _ 3 / 'Am I ! ZC� <br /> Comments Included: - 6 D/_Ifs� <br /> Business Rep's Signature Phone Number Inspector's Signature Phone Number <br /> 62081 <br /> INSTRUCTIONS ON BACK Correct:® Incorrect: EXAMPLE 1 2 3 <br /> 0 White Copy:CalRecycle Yellow Copy:Operator Pink Copy:LEA © ■ <br />