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Waste Tire SL. .tey & Inspection Report inspection Report Number <br /> CalRecycle State of California — <br /> CalRecycle181(Rev.10/10) Survey Form - Page 1 I1 1230191 <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 � � � Cc, <br /> Inspection Type(Fill one) <br /> Site Suffix: « Routine Q Re-inspection Q Referral Q Observation <br /> Local r� If Referral,choose referral type(Fill one) <br /> Identifier: Sf�h 1 -���� 61, Q CHP Q CalRecycle Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name V Inspected By Inspector <br /> Physical Address <br /> /V <br /> 5�5 ", <br /> )Nlkyll� <br /> Inspection Date � 1 / i C3 <br /> C 53?6 1 77 <br /> Time In Time Out <br /> Business Rep ` Title J *AM 10 AM <br /> / "l�1'1� t/�jL��d � *1 0 PM S 0 PM <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 /> ' ' 16 Active * Passenger 0 Generator •Outdoor <br /> O Q Closed Q Altered <br /> GPS Latitude Q Hauler Q Indoor <br /> O Q Inactive Q Truck <br /> Longitude — Q Planned Q OTR Q End-Use Q Container <br /> Business Type(Fill all that apply) <br /> 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 40 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 <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 /> QQ 14 CCR§18459-Responsible Entities Complying with Manifesting Requirements Date FTI / 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) <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 <br /> In Compliance-No Violations o <br /> Q 1 Q Other:§ <br /> z <br /> Comments <br /> CA <br /> �c5 \�i c� •moi py�S� CNC- /metas G V�C,2t'y\. <br /> Inspection Form Included: Q . � � <br /> Comments Included: - <br /> 41 <br /> businesp4elifs Signature Phone Number In;;4eCtori Signature Phone Number <br /> INSTRUCTIONS ON BACK Correct:* Incorrect: __47 EXAMPLE 1112 3 62081 <br /> ® White Copy:CalRecycle Yellow Copy:Operator Pink Copy:LEA ® ■ <br />