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Waste Tire Survey & Inspection Report Inspection Report Number ■ <br /> CalRecle State of California <br /> cycle CalRecycle 181(Rev.10/10) Survey Form - Page 1 I1 - 1230299 <br /> Dept.of Resources Recycling and Recovery(CalRecycle) <br /> Part A- Survey BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- y � � Q c � � _ Q � Inspection Type(Fill one) <br /> Site Suffix: r l J 0 Routine Q Re-inspection 0 Referral Q Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier: SQtr, dry„Utl^ �O An ' 0 CHP Q CalRecycle Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name� _" 1 Inspected By Inspector <br /> rYl <br /> J\,�(Q.SS Tf(A AQ n <br /> N Q <br /> Physical Address J 1 D <br /> e�N w a4 an l5l of c)j b <br /> Inspection Date (� I S <br /> p ian 61'$j-r 6 <br /> Time In Time Out <br /> Business Rep Title (� S O AM t 0 O AM <br /> l � <br /> Onar l kf"<nc QPM 0P o 5- M � , <br /> Operational Status Tire Type Business Role Storage Type <br /> Tire Count(Whole/PTE) r� C (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> 0 Active ® Passenger 0 Generator 0 Outdoor <br /> O O Closed Q Altered <br /> �PS Latitude Q Hauler ® Indoor <br /> O O Inactive ® Truck <br /> Longitude - Q Planned Q OTR O 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 ® Other "Ja k a LA'5& <br /> Part B - Inspection of Waste Tire Dealer, Generator, Hauler and End-Use Facility ENFORCEMENT STATUS <br /> V A I HAULING AND MANIFEST REQUIREMENTS <br /> O O PRC§42951 -Waste Tire Hauler Registration and Transport of Tires Notice Of Violation Extension <br /> O O PRC§42953-Contracts with Registered Waste Tire Haulers. Compliance Deadline <br /> O Q PRC§42956-Registration/Decal in Vehicle <br /> O 0 14 CCR§18459-Responsible Entities Complying with Manifesting Requirements Date <br /> M / M / m <br /> O 0 14 CCR§18459.1 -Tire Program ID Number from CalRecycle � <br /> O Q 14 CCR§18459.2.1 -Submittal of Comprehensive Trip Logs within 90 days (Required for NOV or EXTJ N <br /> a <br /> O O 14 CCR§18459.3-Retention of Comprehensive Trip Logs for 3 years o <br /> 0 O 14 CCR§18460.2-Manifest System Requirements for Registered Waste Tire Haulers Q Referred/CalRecycle Enforcement <br /> Q O 14 CCR§18461 -Manifest System Requirements for Waste Tire End-Use Facilities w <br /> O O 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators O In Compliance-No Violations o <br /> O O Other:§ <br /> Comments Qk' 1 A!' f -�L'­, /n / <br /> J ,U NiO aAbnS of u IC-wk UylLF-rn. <br /> Inspection Form Included: <br /> 4usmess <br /> Comments Included: 1 p's Signature Phone Number Inspe is Signature Phone Number <br /> INSTRUCTIONS ON BACK orrect:0 Incorrect: 7V2�0 62081 EXAM L E 1 2 3 <br /> ■ White Copy:CalRecycle Yellow Copy:Operator Pink Copy: A © 0 <br />