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Waste Tire Sup vey & Inspection Report Inspection Report Number <br /> CalRecycle State of California <br /> R I 1 1177520 <br /> CalRecycle 181(Rev.10/10) <br /> y(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- S b 5 `i (D _ 0 Inspection Type(Fill one) <br /> Site Suffix: <br /> ® Routine Q Re-inspection Q Referral Q Observation <br /> Localr /� If Referral,choose referral type(Fill one) <br /> Identifier: S(��J p �y,, 1 Q CHP Q CalRecycle Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name <br /> Inspected By Inspector <br /> Physical Address - d <br /> � ` �O n ���U� Inspection Date � / � <br /> 0 a / <br /> C\ Time In Time Outl <br /> Business Rep Title I a O ® AM AM <br /> I I U PM <br /> U PM 1 <br /> -- Operational Status Tire 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 /> • Active Q Passenger A Generator ® Outdoor <br /> O Q Closed Q Altered <br /> GPS Latitude Q Hauler Q Indoor <br /> O Q Inactive 0 Truck <br /> Longitude - Q Planned ® OTR Q End-Use ® 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 l <br /> Q Service Station Q Hauler Q Agriculture Q Shredder ® 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 Q - - — Q Notice Of Violation Q Extension <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 EXT) 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 <br /> Q Q 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators In Compliance-No Violations o <br /> Q 10 1 Other:§ ,� �' j� A <br /> Comments 9—Z%.t\(10- ,n1 f1�S CS -�\Scr 1!� /yl Un jl` t ()A $ Jt_j VI 1(1 CA T�0Q <br /> �1i O�(Af"As 01 roc cry' c U1)corn <br /> Inspection Form Included: Qe& <br /> �^ <br /> Comments Included: ® r <br /> Busi ess p's Signature Phone Number Ins tor's Signatu a Phone Number <br /> INSTRUCTIONS ON BACK I Correct: Incorrect: E X A 4 1 111213 62081 <br /> ■ White Copy:CalRecycle Yellow Copy:Operator Pink Co :L ® ■ <br />