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Waste Tire S#vey & Inspection RepoOnspection Report Number <br /> CalRecycle State of California T — ■ <br /> CalRecycle181(Rev.10/10) Survey Form - Page 1 1 <br /> 1244959Dept.of Resources Recycling and Recovery(CalRecycle) <br /> Part A - Survey__ BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- Inspection I Inspection Type(Fill one) <br /> Site Suffix: � -s • Routine 0 Re-inspection 0 Referral 0 Observation <br /> Local — —� If Referral,choose referral type(Fill one) <br /> Identifier: San ptl,.{j/t � 0 CHP 0 CalRecycle 0 Complaint 0 Educational Visit 0 Other <br /> Business or Facility Name <br /> 1 Inspected By Inspector <br /> C I '1p�. �() �1 FC,.S I I <br /> O <br /> Physical Address I �s Lb�'T� <br /> c Inspection Date '7 <br /> �sLfA��^ CA �J�� Time In Time Out <br /> Business Rep Title c ® AM Q Q AM <br /> OPM <br /> 1 ,o Own J O ® PM <br /> vS�' �� w n Operational Status Tire Type Business Role Storage Type <br /> Tire Count (Whole/PTE) U (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> 1 ® Active 0 Passenger ® Generator I* Outdoor <br /> 0 0 Closed 0 Altered <br /> GPS Latitude 0 Hauler ® Indoor <br /> 0 0 Inactive 0 Truck <br /> Longitude - 0 Planned 0 OTR 0 End-Use 0 Container <br /> Business Type(Fill all that apply) <br /> New Tire Dealer 0 Auto Repair 0 Trucking Fleet 0 Government 0 Retreader 0 Dismantler 0 Tire Derived Fuel <br /> ® Used Tire Dealer 0 Auto Body 0 Car Dealer 0 Collection 0 Crumb Rubber <br /> 0 Service Station 0 Hauler 0 Agriculture 0 Shredder 0 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 /> 0 Notice Of Violation 0 Extension <br /> 0 0 PRC§42951 -Waste Tire Hauler Registration and Transport of Tires <br /> 0 0 PRC§42953-Contracts with Registered Waste Tire Haulers. Compliance Deadline <br /> PRC§42956-Registration/Decal in Vehicle <br /> 0 0 14 CCR§18459-Responsible Entities Complying with Manifesting Requirements Date <br /> 0 0 14 CCR§18459.1 -Tire Program ID Number from CalRecycle <br /> 0 0 14 CCR§18459.2.1 -Submittal of Comprehensive Trip Logs within 90 days (Required for NOV or EXE N <br /> 0 0 14 CCR§18459.3-Retention of Comprehensive Trip Logs for 3 years <br /> a <br /> 0 0 14 CCR§18460.2-Manifest System Requirements for Registered Waste Tire Haulers 0 Referred/CalRecycle Enforcement <br /> 0 0 14 CCR§18461 -Manifest System Requirements for Waste Tire End-Use Facilities w <br /> 0 0 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators In Compliance-No Violations o <br /> Other:§ <br /> z <br /> 0 1 0 1 <br /> Comments QXrAn,-R- W +t I" 1 t LL <br /> Inspection Form Included: 0 �-�- / C/ 7 <br /> Comments Included: t4-91-- '81&-s Sl- o"V <br /> Business Rep's Signature Phone Number Ins ctor's Signature Phone Number <br /> INSTRUCTIONS ON BACK Correct a Incorrect: g IEIXIAIMIPILIEI 1112 3 62081 <br /> ■ White Copy:CalRecycle Yellow Copy:Operator Pink Copy:LEA ® ■ <br />