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Waste Tire Sulo jey & Inspection Report inspection Report Number ■ <br /> State of California <br /> CalRecycle — <br /> CalRecycle 181(Rev.10/10) Survey Form - Page 1 I1 1210370 <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: ` 0 Routine Q Re-inspection Q Referral Q Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier: SGI� Ta Qq V l y\ (S256y\�y Q CHP Q CalRecycle Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name Inspected By Inspector <br /> - ti d I MTTv <br /> Physical Address <br /> 1219 O Snvk�\ I rC'k / <br /> 'VCct` I� <br /> a � Inspection Date s � Z <br /> / Time In Time Out <br /> Business Rep TitleAM AM <br /> _ � © © ® 0 PM 0 PM <br /> ?a �'QQIV-Nn2� <br /> Operational Status Tire Type Business Role Storage Type <br /> Tire Count(Whole/PTE) 1 2 (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> * Active Q Passenger 0 Generator • 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 Q Container <br /> Business Type(Fill all that apply) <br /> Q New Tire Dealer Q Auto Repair 0 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 Q Other <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 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 m / m / m <br /> Q Q 14 CCR§18459.1 -Tire Program ID Number from CalRecycle a <br /> Q Q 14 CCR§18459.2.1 -Submittal of Comprehensive Trip Logs within 90 days (Required for NOV or EX7) 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 •In Compliance-No Violations o <br /> Q Q Other:§ 11 ` <br /> Comments - \ o n <br /> tt `` Q r\ <br /> T IZ_ kO oc W S Yl. <br /> Conce.crt Vc9s Co cl'2c�k <br /> Ar <br /> kc—:> °L�X0111 kAov�5 ©� �'e�S �� CnnCcc <br /> Inspection Form Included: Q r' <br /> Comments Included: 9 ���V��" Iff— 2.oq-N/��'3Z$N <br /> Business Rep's Signature Phone Number Insp ctor's Signature Phone Number <br /> �( <br /> INSTRUCTIONS ON BACK Correct:0 Incorrect: X � NJ E X A M P L E 1112 3 62081 <br /> ■ White Copy:CalRecycle Yellow Copy:Operator Pink Copy:LEA © . <br />