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Waste Tire Survey & Inspection Report Inspection Report Number <br /> CalRecycle State of California ■ <br /> CalRecycle 181(Rev.10/10) Su —rvey Form - Page 1 I1 119 6 3 8 5 <br /> Dept.of Resources Recycling and Recovery(CalRecycle) <br /> Part A-Survey BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- ' / O Inspection Type(Fill one) <br /> Site Suffix: l� 1 0 Routine Q Re-inspection Q Referral Q Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier: Sam J 0" 1,3,I r\ ��l r'1�U Q CHP Q CalRecycle Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name V J Inspected By Inspector <br /> F; (4 ca-'sabot q _ <br /> Physical Address 3 I CS 007- <br /> �OoS � av,� Qr. <br /> tt Inspection Date ` / 0 W / <br /> sio c �� `l SZ d� l <br /> Time In Time Out <br /> Business Rep Title O AM 2 rl O AM <br /> U1fa �L�� SY,O(J '� r- I 0 v a PM � J V 0 PM <br /> NJ Operational Status Tire Type Business Role Storage Type <br /> Tire Count(Whole/PTE) n (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> * Active Q Passenger (9 Generator Q Outdoor <br /> O Q Closed Q Altered <br /> GPS Latitude Q Hauler ® Indoor <br /> O Q Inactive • 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 ® 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 N <br /> Q Q 14 CCR§18459.1 -Tire Program ID Number from CalRecycle 3 <br /> Q O 14 CCR§18459.2.1 -Submittal of Comprehensive Trip Logs within 90 days (Required for NOV or EXE N <br /> Q O 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 O 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators O In Compliance-No Violations o <br /> Q Q Other:§ <br /> z <br /> CommentsI A rJ7 Q-1_ )f 11 05PUM D`71 un f C a,- A R _ <br /> Nu VITAWMns of C4,Jt.(k,' 0� (pnLn�n <br /> Inspection Form Included: Q ZOGI 1� -7797 <br /> Comments Included: *---- <br /> Business Rep's Signature Phone Number Ins a tor's Signature "l-Phone Number <br /> INSTRUCTIONS ON BACK [correct:0 Incorrect: EXAMI P L E 112 3 62081 <br /> ■ White Copy:CalRecycle Yellow Copy:Operator Pink Copy L ® ■ <br />