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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 - 1177605 <br /> Dept.of Resources Recycling and Recovery(CalRecycle) <br /> Part A-Survey BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- c e-t _ r� Inspection Type(Fill one) <br /> Site Suffix: J 1 v 0 Routine Q Re-inspection Q Referral Q Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier: Seu, J 14" � ��,�� Q CHP Q CalRecycle Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name <br /> Inspected By Inspector <br /> Sal �.�a ,-- ����,� �1 u�� � �ow _ /l <br /> Physical Address I I Q CS co'1T C) <br /> LA�3� NW400 -- <br /> Inspection Date ) 1 / J J a 3 <br /> Time In Time Out <br /> Business Rep Title 1 I S O AM I` 5 O AM <br /> ` l ® PM PM <br /> s A l AON, <br /> Operational Status Tine 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 /> 41 f Active Q Passenger ® Generator ® Outdoor <br /> O Q Closed Q Altered <br /> GPS Latitude Q Hauler Q Indoor <br /> O Q Inactive 49 Truck <br /> Longitude - Q Planned Q OTR Q End-Use ® Container <br /> Business Type(Fill all that apply) <br /> Q New Tire Dealer Q Auto Repair 10 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 /> PRC§42956-Registration/Decal in Vehicle <br /> Q Q 14 CCR§18459-Responsible Entities Complying with Manifesting Requirements Date m / m / m <br /> 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 EX7) 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 /> Uj <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 Q Other:§ <br /> Comments 1D1k+,N— nA +1n 40110w) <br /> SGS Cti n�er�'• _ <br /> Inspection Form aw Included: Q �$�_°v _3�� <br /> Comments Included: <br /> BlAsiness Re s Ign a Phone Number Ins tor's Signature Phone Number <br /> INSTRUCTIONS ON BACK Correct:0 Incorrect: g E X A L1 11 2 3 62081 <br /> ■ White Copy:CalRecycle Yellow Copy:Operator Pink Cop :L ® ■ <br />