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Waste Tire Survey & Inspection Report'Onspection Report Number <br /> State of <br /> CalRecycle CalRecyclellfornia 181(Rev.10/10) <br /> Dept.of Resources Recycling and Recovery(CalRecycle) Survey Form Page 1 11 1242293 <br /> Part A- Survey BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- t t ' S15 I _ Inspection Type(Fill one) <br /> Site Suffix: 1 l ®Routine Q Re-inspection Q Referral Q Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier: San 30 (Al )�` u Q CHP Q CalRecycle Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name <br /> Inspected By Inspector <br /> ` _ 1 t <br /> Physical Address 0 C S C6TTO <br /> stc) A I S- <br /> !S Inspection Date <br /> Time In Time Out 1 <br /> Business Rep Title / AM //11 •AM <br /> m g('- I � 3 V O PM � � 0 V QPM <br /> C' Operational Status Tire Type Business Role Storage Type <br /> a (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> Tire Count(Whole/PTE) <br /> ® Active a Passenger ® Generator 0 Outdoor <br /> O Q Closed Q Altered <br /> GPS Latitude Q Hauler ® Indoor <br /> O Q Inactive 0 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 Q Hauler Q Agriculture Q Shredder IS Otherf�(,(ly��rwG�jlrQf- <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 /> Q Q PRC§42956-Registration/Decal in Vehicle <br /> Q Q 14 CCR§18459-Responsible Entities Complying with Manifesting Requirements Date <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) <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 /> 2 <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 ®In Compliance-No Violations o <br /> Q 1 Q Other:§ <br /> Comments ,ne, wash, � rv /4 6C17 a okT)lf— <br /> WOW <br /> N <br /> 1 r) J)O+GA <br /> Inspection Form Included: Q <br /> Comments Included: ® ��- � �� <br /> Business Rep's Signature Phone Number Inspe s Signature Phone Number <br /> INSTRUCTIONS ON BACK Correct: Incorrect: X �7V EJX� 1112131 62081 <br /> ■ White Copy:CalRecycle Yellow Copy:Operator Pink <br /> � r <br />