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Inspection Report Number <br /> Waste Tire S.. Vey & Inspection Report <br /> CalRec cle State of California — <br /> Y CalRecycle 181(Rev.10/10) Survey Form - Page 1 I1 1245229 <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 Type(Fill one) <br /> � � � � � - <br /> Site Suffix: d Routine Q Re-inspection Q Referral Q Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier: aki- Q CHP Q CalRecycle Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name Inspected By Inspector <br /> U n I VL>-SC('t SSI)+(Q-- '27v- - C) <br /> Physical Address ' Spiy ,rc� <br /> _t>-2-05 S . I ho�(D :5fi"_L4- <br /> Inspection Date / o 4 <br /> Time In Time Out <br /> Business Rep Title0 AM/� <br /> ►T�"r" �J0 AM <br /> 0 40 PM Z ' 5 -7 d 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 /> • Active Q Passenger S Generator 40 Outdoor <br /> Q Closed Q Altered <br /> GPS Latitude Q Hauler Q Indoor <br /> O Q Inactive • Truck <br /> Longitude - Q Planned OTR Q End-Use 16 Container <br /> Ir <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 ® Other D'leT(,Lb <br /> Part B - Inspection of Waste Tire Dealer, Generator, Hauler and End-Use Facility ENFORCEMENT STA US <br /> V A HAULING AND MANIFEST REQUIREMENTS <br /> Q Q Q Notice Of Violation Q Extension <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 <br /> 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 EXT) N <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 /> Lu <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 O In Compliance-No Violations o <br /> Q Q Other:§ <br /> Comments Tk�_ �y <br /> Inspection Form Included: Q <br /> Comments Included: <br /> Business Rep's Signature Phone Number Inspector's Signature Phone Number <br /> �( <br /> INSTRUCTIONS ON BACK Correct:0 Incorrect: NJ E X A M L 1 2 3 62081 <br /> ■ White Copy:CalRecycle Yellow Copy:Operator Pink Copy.ALEf <br />