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r <br /> Waste Tire St., vey & Inspection Report. Inspection Report Number <br /> cle State of California <br /> CalRecycle CalRecycle 181(Rev.10110) <br /> Survey Form - Page 1 11 - 1210215 <br /> Recycle) <br /> Dept.of Resources Recycling and Recovery(Cal <br /> Part A-Survey BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- Inspection Type(Fill one) <br /> Site Suffix: 6 „� -7 j (� 1 ® Routine Q Re-inspection Q Referral Q Observation <br /> Local `- If Referral,choose referral type(Fill one) <br /> San, eovy� ,tLi Q CHP Q CalRecycle Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name Inspected By Inspector <br /> Physical Address <br /> _gcs> _s, Gh.erz*-,­c_ <br /> LCF) ; CA qsayv Inspection Date -� / � � / 1 <br /> Time In Time Out <br /> Business Rep Title O AM 0 AM <br /> � <br /> �j (� {,� -�J� -Z c;- J ® P M 10 PM <br /> Operational Status Tire Type Business Role Storage Type <br /> Tire Count (Whole/PTE) 0 © (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> ® Active ® Passenger * Generator ® Outdoor <br /> O Q Closed Q Altered <br /> GP� Latitude Q Hauler Q Indoor <br /> o Q Inactive Q Truck <br /> Longitude - Q Planned Q OTR Q End-Use Q Container <br /> Business Type(Fill all that apply) <br /> ® New Tire Dealer ®Auto Repair Q Trucking Fleet Q Government Q Retreader Q Dismantler Q Tire Derived Fuel <br /> ® 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 /> ®Notice Of Violation 0 Extension <br /> Q Q PRC§42951 -Waste Tire Hauler Registration and Transport of Tires <br /> 0 Q PRC§42953-Contracts with Registered Waste Tire Haulers. Compliance Deadline <br /> PRC§42956-Registration/Decal in Vehicle <br /> QQ 14 CCR§18459-Responsible Entities Complying with Manifesting Requirements Date F�l l / R� <br /> Q Q 14 CCR§18459.1 -Tire Program ID Number from CalRecycle N <br /> Q Q 14 CCR§18459.2.1 -Submittal of Comprehensive Trip Logs within 90 days (Required for NOV or EXn <br /> Q Q 14 CCR§18459.3-Retention of Comprehensive Trip Logs for 3 years <br /> Q Q 14 CCR§18460.2-Manifest System Requirements for Registered Waste Tire Haulers Q Referred/CalRecycle Enforcement <br /> Uj <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 O In Compliance-No Violations o <br /> Q Q Other:§ <br /> z <br /> Comments c <br /> C--�^ <br /> �Cf 0yyt MOnA <br /> Inspection Form Included: O2 <br /> Comments Included: m4"-" �A-6zo3 _492 ' -y 7 <br /> Business Rep's Signature Phone Number I s51fignature Phone Number <br /> INSTRUCTIONS ON BACK Correct: Incorrect: X �t I E I Xj Al P E 1 2 3 62081 <br /> White Copy:CalRecycle Yellow Copy:Operator Pink Copy: <br />