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Waste Tire Sui Bey & Inspection Report inspection Report Number <br /> State of California <br /> CalRec cle — <br /> Y CalRecycle181(Rev.10/10) Survey Form - Page 1 1 1229908 <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 3 3 7 - 0 <br /> f Inspection Type(Fill one) <br /> Site Suffix: f 0 Routine Q Re-inspection Q Referral Q Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier: <br /> l�aig"kj t� CQ V,n Q CHP Q CalRecycle Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name v Inspected By Inspector <br /> Physical Address I d - V 1MAT <br /> 1 v <br /> SNS\ �Y�16. t,.z oo CJS la. — --- - <br /> l CA 9s33 Inspection Date 6 1 / 1 7�, / 1 S <br /> Time In Time Out <br /> Business Rep Title O AM O AM <br /> � 1 � l ' 0 PM � � � BPM <br /> V ��e' t�� �' `"'� ` � 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) <br /> 2 I♦ Active Q Passenger Generator Q Outdoor <br /> O Q Closed Q Altered <br /> GPS Latitude Q Hauler Q Indoor <br /> O Q Inactive 9 Truck <br /> Longitude - End-use Container <br /> Q Planned OTR <br /> Business Type(Fill all that apply) <br /> Q 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 0 Other T �1� M«�• �e <br /> Part B- Inspection of Waste Tire Dealer,Generator, Hauler and End-Use Facility ENFORCEMENT STATUS <br /> V I A I HAULING AND MANIFEST REQUIREMENTS <br /> Q Notice Of Violation Q Extension <br /> Q Q <br /> 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 / m / m <br /> Q Q 14 CCR§18459.1 -Tire Program ID Number from CalRecycle <br /> Q Q 14 CCR§18459.2.1 -Submittal of Comprehensive Trip Logs within 90 days (Required for NOV or EXE N <br /> r <br /> 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 /> W <br /> Q Q 14 CCR§18461 -Manifest System Requirements for Waste Tire End-Use Facilities <br /> Q Q 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators In Compliance-No Violations o <br /> Q Q Other:§ ` - 1� <br /> Comments �sC� \V�c►(J�L�4ir Awnse_on "ti`, <br /> niS <br /> OL �« <br /> Q � <br /> Inspection Form Included: Q '?A,q -7 2 _ ' • ��,,,��Q_3Z� <br /> Comments Included: 0J vu <br /> isin:ess Rep's Signature Phone Number Inspec is Signature Phone Number <br /> ] III62081 <br /> INSTRUCTIONS ON BACK Correct:0 Incorrect: EXAMPLE 1 2 3 <br /> ■ White Copy:CalRecycle Yellow Copy:Operator Pink Copy:LEA <br />