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Inspection Re 0feInspection Report Number <br /> � Waste Tire purvey & Inspec p <br /> Cal Rec cle State of California <br /> Y CalRecycle181(Rev.10/10) Survey Form - Page 1 1 - 1176491 <br /> Dept.of Resources Recycling and Recovery(CalRecycle) <br /> Part A-Survey _ _ ____BLUE_O_R_BLACK_ INK PEN <br /> Business Profile Inspection Details <br /> TPID- Inspection' Inspection Type(Fill one) <br /> n <br /> Site Suffix: / O 0 Routine Q Re-inspection Q Referral Q Observation <br /> Local 1 If Referral,choose referral type(Fill one) <br /> Identifier: San 1:9 1 <br /> uI Q CHP Q CalRecycle Q Complaint Q Educational Visit Q Other <br /> Business or FacilityName <br /> 1 l < Inspected By Inspector <br /> G . �\ , �0 bl 12,�i rc, JeSV1 Lc- - <br /> Physical Address l l Qe(� C S I—oh <br /> Q Inspection Date <br /> C � Time In Time Out 111 <br /> Business Rep TitleO AM C� O AM <br /> I <br /> � 11 3 0P J QPM <br /> -- <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 ® Passenger ® Generator Q Outdoor <br /> Q Closed Q Altered <br /> GPS Latitude 16 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 /> 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 * 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 I 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 /> 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 0 14 CCR§18459.1 -Tire Program ID Number from CalRecycle <br /> Q ® 14 CCR§18459.2.1 -Submittal of Comprehensive Trip Logs within 90 days (Required for NOV or EXT) N <br /> a <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 u, <br /> Q Q 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators = <br /> In Compliance-No Violations o <br /> Q Q Other:§ <br /> z <br /> Comments ? �G � n f 13ufA <br /> N <br /> 1 <br /> < e.s� CUMrnQ,n s of�'(� <br /> Inspection Form Included: Q <br /> Comments Included: 04usine:SSR <br /> (: —.s Signature Ph a Number Insp ors Signature _ Phone Number <br /> INSTRUCTIONS ON BACK Correct:0 Incorrect: EXAM E 2 3 62081 <br /> White Copy:CalRecycle Yellow Copy:Operator Pink Co <br />