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Inspection Report Number <br /> Waste Tire Sw.vey & Inspection Repor. Ins p � <br /> Cal Rec cle State of California <br /> Y CalRecycle 181(Rev.10/10) Survey Form - Page 1 1 - 1226333 <br /> Dept.of Resources Recycling and Recovery(CalRecycle) <br /> Sart A -Survey BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- [ a / Lt t 1 - O I Inspection Type(Fill one) <br /> Site Suffix: 1p ` "I ® Routine Q Re-inspection Q Referral Q Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier: s6k(N JO �1 n (vun' Q CHP Q CalRecycle Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name <br /> Inspected By Inspector <br /> Physical Address <br /> How <br /> Ctow I'n <br /> CA <br /> Inspection Date V 3 I <br /> �s33� <br /> Time In Time Out <br /> Business Rep Title S 0 AM 0 AM <br /> n I 0 PM 0 O PM <br /> SVa-�0.1\101 (4 n 0 W - <br /> Operational Status Tire Type Business Role Storage Type <br /> Tire Count (Whole/PTE) o (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> ® Active Q Passenger ® Generator 0 Outdoor <br /> O Q Closed Q Altered <br /> GPS Latitude Q Hauler Q Indoor <br /> O Q Inactive 40 Truck <br /> Longitude - Q Planned ® OTR Q End-Use Q 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 I- n, L <br /> Q Service Station Q Hauler Q Agriculture Q Shredder 0 Other �Qt l�u81 SPo <br /> SS rkluiu i�tiilu <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 PRC§4295 - Q Notice Of Violation Q Extension <br /> 1 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 /> QQ 14 CCR§18459-Responsible Entities Complying with Manifesting Requirements Date FT / Q / 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 EX7) N <br /> a <br /> 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 /> w <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 Q Other:§ l <br /> Comments n �j J l n�,,�r `�1f NA1 (k(A6 �A Y-1A �C_ <br /> K_-17V�'��� 1,�� 4�e, 11' �- 11�,�`.�-.`''�1)� / i>� tin <br /> �.J <br /> Inspection Form Included: Q r - nn <br /> Comments Included: - 7O �Insp <br /> �� �- Iusin s Rep'sSig ture Phone Number tor's Signature _Phone Number <br /> 62081 <br /> INSTRUCTIONS ON BAC Correct:0 incorrect: E I X I A VP ' L' ( l1213White Copy:CalRecycle Yellow Copy:Operator Pink C ■ <br />