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Waste Tire Survey & Inspection Re orlainspection Report Number <br /> CalRecycle p p I1 - 1242529 <br /> Y State of California <br /> CalRecycle 181(Rev.10/10) Survey Form - Page 1 <br /> Dept.of Resources Recycling and Recovery(calRecycle) <br /> BLUE OR BLACK INK PEN <br /> Part A-survey <br /> Business Profile Inspection Details <br /> TPID- Q Q �^ Inspection Type(Fill one) <br /> Site Suffix: v v � v '9 Routine Q Re-inspection Q Referral Q Observation <br /> CoLocal <br /> If Referral,choose referral type(Fill one) <br /> Identifier: Saln�o a, J If <br /> Q CHP Q CalRecycle Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name Inspected By Inspector <br /> ?[o�Aof s �� fes- c� - co"), - 0 1 <br /> Physical Address J (5-S(,6 �Q <br /> aO s <br /> L, ��- <br /> Inspection Date Q / l l / l —J <br /> aft C °lSaLt <br /> Time In Time Out <br /> Business Rep /� Title q 19 AM <br /> p ILGIM 1 rC�. B ' 3 Q PM I ' S 0 PM <br /> �►arl�f t 1Y�u rlc� Cr <br /> Operational Status Tire Type Business Role Storage Type <br /> (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> Tire Count(Whole/PTE) Q <br /> 41 Active ® Passenger � Generator � Outdoor <br /> O Q Closed Q Altered <br /> GPS Latitude Q Hauler Q Indoor <br /> 0 Q Inactive Q Truck <br /> Longitude - End-Use Q Container <br /> Q Planned Q OTR <br /> Business Type(Fill all that apply) <br /> ® New Tire Dealer A Auto Repair Q Trucking Fleet O Government Q Retreader Q Dismantler Q Tire Derived Fuel <br /> (ID Used Tire Dealer Q Auto Body Q Car Dealer Q Collection Q Crumb Rubber <br /> Q Service Station Q Hauler Q Agriculture 0 Shredder ® Other �b� <br /> Part B - Inspection of Waste Tire Dealer, Generator, Hauler and End-Use Facility ENFORCEMENT STATUS <br /> V A HAULING AND MANIFEST REQUIREMENTS Q Notice Of Violation O Extension <br /> O O PRC§42951 -Waste Tire Hauler Registration and Transport of Tires <br /> O O PRC§42953-Contracts with Registered Waste Tire Haulers. Compliance Deadline <br /> O O PRC§42956-Registration/Decal in Vehicle <br /> O O 14 CCR§18459-Responsible Entities Complying with Manifesting Requirements Date <br /> Q Q 14 CCR§18459.1 -Tire Program ID Number from CalRecycle A <br /> (Required for NOV or EXTJ N <br /> O O <br /> 14 CCR§18459.2.1 -Submittal of Comprehensive Trip Logs within 90 days <br /> Q 0 14 CCR§18459.3-Retention of Comprehensive Trip Logs for 3 years o <br /> O Q 14 CCR§18460.2-Manifest System Requirements for Registered Waste Tire Haulers Q Referred/CalRecycle Enforcement <br /> w <br /> O O 14 CCR§18461 -Manifest System Requirements for Waste Tire End-Use Facilities <br /> O O 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators A In Compliance-No Violations o <br /> O O Other:§ <br /> Comments 9_,0 W4,V, w 4b i?-, <br /> WKk) Was �= <br /> N k,I pl U�1 cn.s o Gan Courn- <br /> v <br /> Inspection Form Included: Q <br /> Comments Included: It <br /> J / 0 <br /> Busi ss Rep's Signature Ph_ umb r Inspec 's Signature Phone Number <br /> 62081 <br /> INSTRUCTIONS ON BACK Correct: Incorrect: � �J E X A M p 1 2 3 <br /> Yellow Copy:0 erator Pink Copy <br /> Lvr <br /> White Copy:CalRecycle PY P <br />