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Waste Tire Su#ey & Inspection Report inspection Report Number <br /> State of California <br /> CalRecycle — <br /> CalRecycle181(Rev.10/10) Survey Form - Page 1 I1 1226304 <br /> Dept.of Resources Recycling and Recovery(CalRecycle) <br /> 'art A-Survey BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- 6 (_ Q O ) Inspection Type(Fill one) <br /> Site Suffix: UC l I ® Routine Q Re-inspection Q Referral Q Observation <br /> Local \ �'n ,_ If Referral,choose referral type(Fill one) <br /> Identifier: S(A O �JC>(,( u W �� Q CHP Q CalRecycle Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name 1 Inspected By Inspector <br /> - I C� SCOO-c�O <br /> Physical Address ) 3 <br /> Inspection Date 5 0 S / 13 <br /> � <br /> Time In Time Out <br /> Business Rep ( Title ] � O AM O AM <br /> ® <br /> PM � O � ® PM <br /> Operational Status Tire Type Business Role Storage Type <br /> Tire Count (Whole/PTE) e (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> ' S 5 ® Active Q Passenger 0 Generator ® Outdoor <br /> O Q Closed Q Altered <br /> GPS Latitude Q Hauler Q Indoor <br /> O Q Inactive * Truck <br /> Longitude - Q Planned Q OTR Q End-Use IN 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 /> PRC§42956-Registration/Decal in Vehicle <br /> Q Q 14 CCR§18459-Responsible Entities Complying with Manifesting Requirements Date m <br /> Q Q 14 CCR§18459.1 -Tire Program ID Number from CalRecycle a <br /> Q Q 14 CCR§18459.2.1 -Submittal of Comprehensive Trip Logs within 90 days (Required for NOV or EXE N <br /> v <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 /> 2 <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:§ �/� - 11 1 1_ <br /> Comments <br /> (�,)1��1� `y W LA {, +l t 1, �-1.t/r"t-r-, � ().n A1_) <br /> 1^11 6 <br /> Inspection Form Included: Q a ' 2�r�� �� a / n <br /> Comments Included: a (D / <br /> Business Rep's Si ature Phone Number aInspeor's SignatureP onfi e Number <br /> INSTRUCTIONS ON BACK I Correct: Incorrect: EXAM L I 11 2 3 I 62081 <br /> White Copy:CalRecycle Yellow Copy:Operator Pink Copy.L �� <br />