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Waste Tire Su. ,rey & Inspection Report inspection Report Number <br /> CalRecycle CalRecycle'181(Rev.10/10) 1242471 11 — <br /> Dept.of Resources Recycling and Recovery(CalRecycle) Survey Form o Page " <br /> Part A- Survey BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- f , 1 � � O O � Inspection Type(Fill one) <br /> Site Suffix: N 110 Routine Q Re-inspection Q Referral Q Observation <br /> Local L>�u�� If Referral,choose referral type(Fill one) <br /> Identifier: SPA(1 J w1 LA 4-) O CHP Q CalRecycle Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name I Inspected By Inspector <br /> S Mps0r` - 1 0 <br /> Physical Address I Cs L07T U <br /> 515 1 S: 1�avft ��— <br /> Inspection Date <br /> Time In Time Out <br /> Business Rep 1 Title L � ^ C 0 AM 0 AM <br /> 1..��'1 S �7 /)PflGlfo.. `SO�U(hrtn f d J ® PM � � � 0 PM <br /> p 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 /> e ® Active 0 Passenger 0 Generator Q Outdoor <br /> O Q Closed Q Altered tJ/A <br /> GpS Latitude Q Hauler Q Indoor <br /> O Q Inactive Q Truck <br /> Longitude - 0 Planned ® OTR 0 End-Use Q Container <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 1 <br /> Q Service Station Q Hauler Q Agriculture Q Shredder B Other S }�� (1�Knu�Ltll��1 <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 /> O O <br /> PRC§42951 -Waste Tire Hauler Registration and Transport of Tires <br /> O O PRC§42953-Contracts with Registered Waste Tire Haulers. Compliance Deadline <br /> PRC§42956-Registration/Decal in Vehicle <br /> O O 14 CCR§18459-Responsible Entities Complying with Manifesting Requirements Date m / m / m <br /> 0 O 14 CCR§18459.1 -Tire Program ID Number from CalRecycle <br /> Q O 14 CCR§18459.2.1 -Submittal of Comprehensive Trip Logs within 90 days (Required for NOV or EXT) N <br /> a <br /> Q ® 14 CCR§18459.3-Retention of Comprehensive Trip Logs for 3 years c <br /> Q O 14 CCR§18460.2-Manifest System Requirements for Registered Waste Tire Haulers O Referred/CalRecycle Enforcement <br /> LU <br /> O 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 ®In Compliance-No Violations o <br /> 0 1 Q 1 Other:§ 1 l <br /> Comments L ,1 �.� t of 1 } 'S u/ y GLC1U` + �lU1n7�'� <br /> I ytA 'La Ic, 1 nSC?�� LAmn� U <br /> Inspection Form Included <br /> Comments Included: ® <br /> Business Rep's Signature Phone Number Ins tor's Signature Phone Number <br /> INSTRUCTIONS ON BACK Correct* Incorrect: IEIXIAIM L E 1 2 3 62081 <br /> ® White Copy:CalRecycle Yellow Copy:Operator Pink Copy L ® ■ <br />