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Waste Tire Sup Bey & Inspection Report Inspection Report Number <br /> Cal ReC cle State of California <br /> Y CalRecycle 181(Rev.10/10) Survey Form - Page 1 I1 1196558 <br /> Dept.of Resources Recycling and Recovery(CalRecycle) <br /> Part A-Survey BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- 0 --z <br /> l , � � � _ O � Inspection Type(Fill one) <br /> Site Suffix: "I 0 Routine 0 Re-inspection 0 Referral 0 Observation <br /> LocalIf Referral,choose referral type(Fill one) <br /> Identifier: SCLh �C) C 0 V Y\vV 0 CHP 0 CalRecycle 0 Complaint 0 Educational Visit 0 Other <br /> Business or Facility Name Inspected By Inspector <br /> r <br /> Physi al GO,� J�eS �Y`C Q � Mress <br /> Inspection Date 1 / 07 <br /> Pko'A 1 <br /> Time In Time Out <br /> Business Rep Title 20 AM O AM <br /> S C e ) O 0 PM 0 PM <br /> Operational Status Tire Type Business Role Storage Type <br /> Tire Count (Whole/PTE) (Fill one only) (FII all that apply) (Fill all that apply) (Fill all that apply) <br /> C <br /> 5 0 Active 0 Passenger 0 Generator 0 Outdoor <br /> O 0 Closed 0 Altered <br /> GPS Latitude 0 Hauler 0 Indoor <br /> 0 0 Inactive 0 Truck <br /> Longitude — 0 Planned 0 OTR 0 End-Use 0 Container <br /> Business Type(Fill all that apply) <br /> 0 New Tire Dealer 0 Auto Repair 0 Trucking Fleet 0 Government 0 Retreader 0 Dismantler 0 Tire Derived Fuel <br /> 0 Used Tire Dealer 0 Auto Body 0 Car Dealer 0 Collection 0 Crumb Rubber <br /> 0 Service Station 0 Hauler 0 Agriculture 0 Shredder 0 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 /> 0 00 Notice Of Violation 0 Extension <br /> PRC§42951 -Waste Tire Hauler Registration and Transport of Tires <br /> 0 0 PRC§42953-Contracts with Registered Waste Tire Haulers. Compliance Deadline <br /> PRC§42956-Registration/Decal in Vehicle <br /> 0 0 14 CCR§18459-Responsible Entities Complying with Manifesting Requirements Date <br /> 0 0 14 CCR§18459.1 -Tire Program ID Number from CalRecycle N <br /> 0 0 14 CCR§18459.2.1 -Submittal of Comprehensive Trip Logs within 90 days (Required for NOV or EXE N <br /> 0 0 14 CCR§18459.3-Retention of Comprehensive Trip Logs for 3 years o <br /> 0 0 14 CCR§18460.2-Manifest System Requirements for Registered Waste Tire Haulers 0 Referred/CalRecycle Enforcement <br /> LU <br /> 0 0 14 CCR§18461 -Manifest System Requirements for Waste Tire End-Use Facilities W <br /> 0 0 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators In Compliance-No Violations o <br /> 0 1 0 1 Other:§ <br /> Comments CNN <br /> Inspection Form Included: 0 / 20'?-239--13461 S, , <br /> Comments Included: <br /> Signat Phone Number Inspectors'Signature Phone Number <br /> Busi essWs <br /> INSTRUCTIONS ON BACK Correct:0 Incorrect: EXAMPLE 1112 3 62081 <br /> ® White Copy:CalRecycle Yellow Copy:Operator Pink Copy:LEA ® ■ <br />