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Waste Tire SL. .ey & Inspection Report Inspection Report Number ■ <br /> State of California <br /> CalRecycle — <br /> CalRecycle 181(Rev.10/10) Survey Form - Page 1 I1 1242420 <br /> Dept.of Resources Recycling and Recovery(CalRecycle) <br /> Part A- Survrr ____— BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- ' -7 V 8 '3 "A - © 1 Inspection Type(Fill one) <br /> Site <br /> Site Suffix: I* Routine Q Re-inspection Q Referral Q Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier: SG-h � v� �� Q CHP Q CalRecycle Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name \ `` f Inspected By Inspector <br /> ' <br /> 4eo,Kk\ac,CtyT Ce� �CeCJ•V C�� 3 C� - 1 ` M \ v <br /> Physical Address <br /> 2\3 �CCe,\\•� S� <br /> Inspection Date O 6 3 <br /> uct-&\ CX 0lseno <br /> Time In Time Out <br /> Business Rep Title c O AM0 AM <br /> O PM O 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 /> i Active Q Passenger 0 Generator Q Ofudoor <br /> O Q Closed Q Altered A' <br /> GPS Latitude Q Hauler Q Indoor <br /> O Q Inactive Q Truck <br /> Longitude - Q Planned 40 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 <br /> Q Service Station Q Hauler Q Agriculture Q Shredder 0 Other L �0.� S�n,av� K:; , <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 /> Q Q PRC§42956-Registration/Decal in Vehicle <br /> Q Q 14 CCR§18459-Responsible Entities Complying with Manifesting Requirements Date m 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 E)C7) <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 /> Q Q 14 CCR§18461 -Manifest System Requirements for Waste Tire End-Use Facilities W <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:§ <br /> Comments <br /> npix <br /> cin <br /> Inspection Form Included: Q ze)f-Va2- <br /> f3 <br /> 3 <br /> Comments Included: QQ L>D <br /> Busine Rep' Signature Phone Number Insp tor's Signature Phone Number <br /> INSTRUCTIONS ON BACK Correct:I. Incorrect: EIXIAIMIPILIE1 1112 3 62081 <br /> ■ White Copy:CalRecycle Yellow Copy:Operator Pink Copy:LEA ® ■ <br />