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Waste Tire Su. rey & Inspection Report Inspection Report Number ■ <br /> State of California <br /> CalRecycle 11 - 1196306 <br /> CalRecycle 181(Rev.10/10) <br /> (Cal Survey Form - Page 1 <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� � � ' 1 � _ b t Inspection Type(Fill one) <br /> Site Suffix: "� 0 Routine Q Re-inspection Q Referral Q Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier: so'V\ Q CHP Q CalRecycle Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name✓ \\ Inspected By Inspector <br /> Physic�aC:ca�AAdd�ress N`o_kcc�a� <br /> 2 331 S\-0�cQa-CL. 1Z-c - <br /> O x 9S 2�s Inspection Date O 1 r s 1 tA <br /> S `_�v. Time In Time Out I <br /> Business Rep Title 2 *AM ` 1 1 !AM <br /> / 5 Q PM 6 l 0 PM <br /> Operational Status Tire Type Business Role Storage Type <br /> Tire Count(Whol <br /> (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> /PT <br /> 0 Active Q Passenger 0 Generator 0 Outdoor <br /> Q Closed Q Altered <br /> GPS Latitude Q Hauler Q Indoor <br /> 0 Q Inactive Q Truck <br /> Longitude — Q Planned 0 OTR Q End-Use 0 Container <br /> Business Type(Fill all that apply)' <br /> Q New Tire Dealer Q Auto Repair Q Trucking Fleet Q Government Q Retreader 0 Dismantler Q Tire Derived Fuel <br /> Q Used Tire Dealer Q Auto Body Q Car Dealer Q Collection Q Crumb Rubber <br /> 61 . 1 <br /> Q Service Station Q Hauler Q Agriculture Q Shredder • Other tjll rr �(-' <br /> Part B - Inspection of Waste Tire Dealer, Generator, Hauler and End-Use Facility ENFORCEMENT STATUS_ <br /> V A HAULING AND MANIFEST REQUIREMENTS <br /> Q Notice Of Violation Q Extension <br /> Q Q <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 /> PRC§42956-Registration/Decal in Vehicle <br /> Q Q 14 CCR§18459-Responsible Entities Complying with Manifesting Requirements Date 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 EXE 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 /> 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 I*In Compliance-No Violations o <br /> Q Q Other:§ \ ` <br /> Comments Q_— & � Cxh h <br /> Inspection Form Included: Q <br /> Comments Included: , <br /> siness Rep' ignature Phone Number AJSignature Phone Number <br /> �,( 62081 <br /> INSTRUCTIONS ON BACK Correct: Incorrect: � , NJ E�X�A�MJPJLJEJ 1112 3 <br /> White Copy:CalRecycle Yellow Copy:Operator Pink Copy:LEA © ■ <br />