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I <br /> Waste Tire SG. vey & Inspection Repoi t. Inspection Report Number <br /> CalRecycle State of California I 1 - 1226619 <br /> CalRecycle 181(Rev.10/10) <br /> (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- I cJ O e�1 - i Inspection Type(Fill one) <br /> Site Suffix. 1 I 40 Routine Q Re-inspection Q Referral Q Observation <br /> LocalIf Referral,choose referral type(Fill one) <br /> Identifier: S Ck ��r "I� Co u-n+'i 1 0 CHP Q CalRecycle Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name "1 Inspected By Inspector <br /> old (c'_-s�l e- G's Cci,S+ <br /> Physical Address <br /> (o �� � Linnc_ <br /> Inspection Date <br /> CL C C � <br /> l 7 Time In Time Out <br /> Business Rep Title l AM ® AM <br /> 0 PM I Q 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 /> ,(f <br /> S Active O Passenger ® Generator Q Outdoor <br /> ---- NA <br /> GPS Latitude � Closed � Altered <br /> Hauler Q Indoor <br /> ° Q Inactive ® Truck <br /> Longitude - O Planned ® OTR O End-Use Q Container <br /> Business Type(Fill all that apply) "i k Io <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 O Crumb Rubber <br /> Q Service Station O Hauler Q Agriculture Q Shredder Other (on Clea-- ff)LtR44,00 gfel- J <br /> Part B - Inspection of Waste Tire Dealer, Generator, Hauler and End-Use Facility ENFORCEMENT STATUS <br /> V A HAULING AND MANIFEST REQUIREMENTS <br /> O O PRC§42951 -Waste Tire Hauler Registration and Transport of Tires Notice Of Violation Extension <br /> O O PRC§42953-Contracts with Registered Waste Tire Haulers. Compliance Deadline <br /> O O PRC§42956-Registration/Decal in Vehicle <br /> 0 O 14 CCR§18459-Responsible Entities Complying with Manifesting Requirements Date m / m / m <br /> O Q 14 CCR§18459.1 -Tire Program ID Number from CalRecycle <br /> 0 O 14 CCR§18459.2.1 -Submittal of Comprehensive Trip Logs within 90 days (Required for NOV or EXE N <br /> Q Q 14 CCR§18459.3-Retention of Comprehensive Trip Logs for 3 years <br /> 0 O 14 CCR§18460.2-Manifest System Requirements for Registered Waste Tire Haulers O Referred/CalRecycle Enforcement <br /> 0 O 14 CCR§18461 -Manifest System Requirements for Waste Tire End-Use Facilities W <br /> O O 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators <br /> ®In Compliance-No Violations o <br /> O O Other:§ _ <br /> Comments t SC' 1 Jc, 1 i G^ sv— on ocna <br /> �flni_ <br /> N <br /> Inspection Form Included: O <br /> Comments Included: ® 4019- I <br /> Business Rep's Signature Phone Number Inspe is Signature Phone Number <br /> INSTRUCTIONS ON BACK [Correct:* Incorrect: i� � IEIXIAIMIPI LJEJ 1112 3 62081 <br /> ■ White Copy:CalRecycle Yellow Copy:Operator Pink Copy:LEA © ■ <br />