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Waste Tire SL. 4ey & Inspection Report Inspection Report Number <br /> Cal Rec cle State of California — <br /> Y CalRecycle 181(Rev.10/10) Survey Form - Page 1 I1 1242508 <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 O O Y/ Inspection Type(Fill one) <br /> Site Suffix: ` q C ` 0 Routine Q Re-inspection Q Referral Q Observation <br /> LocalIf Referral,choose referral type(Fill one) <br /> Identifier: S a(N J 0 UL411 ��u� Q CHP Q CalRecycle Q Complaint Q Educational Visit Q Other <br /> Business orFacilityName Inspected By Inspector <br /> C 5,�t S W _ <br /> Physical Address �( l Q Cs or 0 <br /> G <br /> Inspection Date <br /> S�Cac,�r 0 CA IS20(� �J <br /> Time In Time Out <br /> Business Rep TitleO AM O AM <br /> � � � ® PM <br /> Vo,1\Isso, t�01j) n GlA O �PM <br /> 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 /> 0 * Active' Q Passenger ® Generator Q pO�utdoor <br /> O Q Closed Q Altered f v� <br /> GPS Latitude Q Hauler Q Indoo <br /> O Q Inactive ® Truck <br /> Longitude - Q Planned ® OTR Q End-Use Q Container <br /> Business Type(Fill all that apply) PU <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 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 /> Q 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 M / m / m <br /> Q Q 14 CCR§18459.1 -Tire Program ID Number from CalRecycle i <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 ®In Compliance-No Violations o <br /> Q Q Other:§ <br /> Comments 11✓�.1 VV�S�y 41l 1 <br /> WtkS c>D ,1'- <br /> No y i1 o4l ons O li n I u S ULLon cx-f n- <br /> Insp ection Form Included: / 1 _ <br /> Comments Included: 0 Oeq <br /> q__ ��1 yit <br /> Business Rep's Signature Phone Number Insp or's Signature Phone Number <br /> INSTRUCTIONS ON BACK Correct: Incorrect: E X A 1112131 <br /> 62081 <br /> White Copy:CalRecycle Yellow Copy:Operator Pink Cop E <br />