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Waste Tire Su. vey & Inspection Report Inspection Report Number <br /> Cal Rec cle State of California <br /> Y CalRecycle 181(Rev.10/10) Survey Form - Page 1 11 - 1230427 <br /> Dept.of Resources Recycling and Recovery(CalRecycle) <br /> Part A-Survey BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- l 1 O U _ Inspection Type(Fill one) <br /> Site Suffix: "� 1 *Routine 0 Re-inspection 0 Referral 0 Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier: SCJ c/1 7—`j V ky'h Cly'. 0 CHP 0 CalRecycle 0 Complaint 0 Educational Visit 0 Other <br /> Business or Facility Name <br /> Inspected By Inspector <br /> Physical Address <br /> IoSc) <br /> Inspection Date � o / <br /> J Time In Time Out <br /> Business Rep Title O AM f O AM <br /> Z O ®PM 40 PM <br /> N.oa occ. r;C <br /> Operational Status Tire Type Business Role Storage Type <br /> Tire Count (Whol /PT (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> Tire Count (WhoIC5 <br /> 4@1 Active 0 Passenger &Generator 0 Outdoor <br /> O 0 Closed 0 Altered <br /> GPS Latitude 0 Hauler Indoor <br /> O 0 Inactive Q Truck <br /> Longitude — 0 Planned 0 OTR 0 End-Use 10 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 1 <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 Notice Of Violation 0 Extension <br /> 0 0 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 /> 00 14 CCR§18459-Responsible Entities Complying with Manifesting Requirements Date M / Ffl / Ffl <br /> 0 0 14 CCR§18459.1 -Tire Program ID Number from CalRecycle <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 /> Uj <br /> W <br /> 0 0 14 CCR§18461 -Manifest System Requirements for Waste Tire End-Use Facilities <br /> 0 0 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators •In Compliance-No Violations o <br /> 0 0 Other:§ <br /> Comments A Q- Py-, AV-iS. Aa\2 C.L4 A-VP,- N <br /> lai kr�ptms �k <br /> O� <br /> Corcvon <br /> Inspection Form�nc <br /> ncluded: <br /> o�4-GING -3sF(Q 2a -�i6�2g <br /> Comments luded: <br /> Busi s R 's Signature Phone Number Inspe tor's Signature Phone Number <br /> �( <br /> INSTRUCTIONS ON BACK I Correct:* <br /> Incorrect: EXAMPLE 1 62081 <br /> 2 3 ® . <br /> ■ White Copy:CalRecycle Yellow Copy:Operator Pink Copy:LEA <br />