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Waste Tire Su, ,iey & Inspection Report inspection Report Number <br /> CalRec cle State of California <br /> Y CalRecycle 181(Rev.10/10) Survey Form - Pie I1 - 1196477 <br /> Dept.of Resources Recycling and Recovery(CalRecycle) <br /> Part A-Survey BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- ' inspection Type(Fill one) <br /> Site Suffix: � 5 � (jI 'z _ 0I �Routine QRe-inspection Q Referral <br /> Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier: SCJ 5p�j V;� r,.�V� Q CHP Q CalRecycle Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name —1 w Inspected By Inspector <br /> Physical Add ss <br /> t�A167 \? 5k, - <br /> Inspection Date Q <br /> Time In Time Out <br /> Business Rep Title 0 AM 1 O AM <br /> S��-� �C'0�0.V✓\ Ma�Q .2.'(— O PM Y . O J 0 PM <br /> Operational Status Tire Type Business Role Storage Type <br /> Tire Count (Whol PTE �-� (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> • Active Passenger 0 Generator Q Outdoor <br /> o Q Closed Q Altered <br /> GP� Latitude Q Hauler 0 Indoor <br /> O Q Inactive IS Truck <br /> Longitude - Q Planned OTR O End-Use 0 Container <br /> Business Type(Fill all that apply) <br /> 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 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 /> 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 /> M / M / m <br /> Q Q 14 CCR§18459.1 -Tire Program ID Number from CalRecycle a <br /> Q Q 14 CCR§18459.2.1 -Submittal of Comprehensive Trip Logs within 90 days (Required for NOV or EXE N <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 o In Compliance-No Violations o <br /> Q Q Other:§ <br /> Comments `` �c��p�,t� Ove <br /> E <br /> Inspection Form Included: o t1C�� Q �j t 1DOI[¢ a <br /> Comments Included: l• w /`� �' / ZU4" ��Zo <br /> Business NO Signature Phone Number Inspector's Signature Phone Number <br /> INSTRUCTIONS ON BACK Correct:0 Incorrect: g EXAMPLE 112 3 62081 <br /> ■ White Copy:CalRecycle Yellow Copy:Operator Pink Copy:LEA ® ■ <br />