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Waste Tire Surve & Inspection Re ort Onspection Report Number <br /> CalRecycle State of California Y <br /> Y CalRecycle 181(Rev.10/10) I1 117 7 5 2 6 <br /> Dept.of Resources Recycling and Recovery(CalRecycle) Survey Form - Pale 1 <br /> Part A-Survey BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- ' S , 3 _ © 1 Inspection Type(Fill one) <br /> Site Suffix: l Routine Q Re-inspection * Referral Q Observation <br /> Localj I f If Referral,choose referral type(Fill one) <br /> Identifier: S�lfl O�tqu,, ^ `vun Q CHP I. CalRecycle Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name Inspected By Inspector <br /> Sun U(Ne C7��1 ass �S�n��r� 3 � e 1 0 ) <br /> Physical Address �� <br /> �'D-tD W. ?; <br /> Inspection Date <br /> Time In e Time Out <br /> Business Rep Title �AM SAM <br /> PM � ' � � QPM <br /> Ll. Q 4ill t2 vo emS <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 /> le Q Active Q Paspnger Q Generator Q Outdoor <br /> O & Closed Q Altere <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 /> Q New Tire Dealer Q Auto Repair ® 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 / Ffl / m <br /> Q Q 14 CCR§18459.1 -Tire Program ID Number from CalRecycle 9 <br /> Q Q 14 CCR§18459.2.1 -Submittal of Comprehensive Trip Logs within 90 days (Required for NOV or EX7) 6i <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 <br /> in Compliance-No Violations o <br /> Q Q Other:§ <br /> Comments \ 1 CA(� LA it r. N <br /> 1z �. Glr(1(A A�. �C7 I W-�(r 1 t c 'n J <br /> 41iInspection Form Included: C <br /> Comments Included: f <br /> B4b/Kevs\s\F16jfg Signature Ohone Number Insp or's Signature Phone Number <br /> INSTRUCTIONSO ACK Correct: Incorrect: KA � � ] <br /> NJ E X A P L1112131 <br /> 1 2 3 62081 <br /> ■ White Copy:CalRecycle Yellow Copy:Operator Pink C ® ■ <br />