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Waste Tire Survey & Inspection Report Inspection Report Number <br /> calRec cle State of California <br /> Y CalRecycle 181(Rev.10/10) Survey Form - Page 1 I1 1210266 <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 /> Site Suffix: G ( J 0 Routine *Re-inspection 0 Referral 0 Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier: 0 CHP 0 CalRecycle 0 Complaint 0 Educational Visit 0 Other <br /> Business or Facility Name Inspected By Inspector <br /> v y�5 1"�"`CSS �SP�✓1L�i " ' --�= ['s 3 �� <br /> Physical Address L <br /> 13.E CA ail . Gi1�rc�l�r�L L✓t . <br /> /� Inspection Date C <br /> � �® Time In Time Out <br /> Business Rep Title J2) AM 60 AM <br /> / 0 . 0 7 QPM C 3 QPM <br /> ~ T � � <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 /> I b ®Active 0 Passenger ® Generator ®Outdoor <br /> O 0 Closed 0 Altered <br /> G PS Latitude 0 Hauler 0 Indoor <br /> 0 0 Inactive Q Truck <br /> Longitude - 0 Planned 0 OTR ® End-Use 0 Container <br /> Business Type(Fill all that apply) <br /> ® New Tire Dealer 0 Auto Repair 0 Trucking Fleet 0 Government 0 Retreader 0 Dismantler 0 Tire Derived Fuel <br /> * Used Tire Dealer 0 Auto Body 0 Car Dealer 0 Collection 0 Crumb Rubber <br /> 0 Service Station 0 Hauler 0 Agriculture 0 Shredder 0 Other Ck✓ <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 /> O 0 - 0 Notice Of Violation 0 Extension <br /> PRC§42951 -Waste Tire Hauler Registration and Transport of Tires <br /> 0 0 PRC§42953-Contracts with Registered Waste Tire Haulers. Compliance Deadline <br /> 0 0 PRC§42956-Registration/Decal in Vehicle <br /> 0 0 14 CCR§18459-Responsible Entities Complying with Manifesting Requirements Date m <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 EXT) 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 /> w <br /> 0 0 14 CCR§18461 -Manifest System Requirements for Waste Tire End-Use Facilities — ___ _ w <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 L <br /> LS VC. - <br /> Inspection Form Included: 0 <br /> "Zc�i - 63 15 41s <br /> Comments Included: <br /> 72 <br /> sin ss ep's Signature Phone Number I e or's 'g ture Phone Number <br /> INSTRUCTIONS ON BACK Correct: Incorrect: IEIXIAIM 1 Z 3 62081 <br /> ■ White Copy:CalRecycle Yellow Copy:Operator Pink Co <br />