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�4 , . <br /> 2 Waste Tire Survey & Inspection Report Inspection Report Number ■ <br /> CalRecycle state of California I 1 - 1210431 <br /> CalRecycle 181(Rev.10/10) 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- © l Inspection Type(Fill one) <br /> Site Suffix: �q d• t ® Routine Q Re-inspection Q Referral Q Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier: S�,l� �p UL Kk>\ ����� Q CHP Q CalRecycle Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name Inspected By Inspector <br /> L�. P. S_ V—fP_i � <br /> Physical Address SA <br /> (j0'5 C"'J co(x L u A'I C v <br /> \ Inspection Date p <br /> S�o�o f, CA gSzcr� 0 <br /> Time In Time Out <br /> Business Rep Title 0 AM (� 0 AM <br /> ' I 5 <br /> is PM 1 C� 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 /> �J Q Active Q P <br /> QAe ^ Q Generator Q Outdoor <br /> PS Latitude o ® Closed eN /A 0 ,1V <br /> GO Q Inactive Q Truck Hauler ndo6ry <br /> Longitude — Q Planned Q 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 /> Used Tire Dealer U Auto Body U Car Dealer U Collection U Crumb Rubber <br /> Q Service Station Q Hauler Q Agriculture Q Shredder Q Other N JA <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 /> 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 EXE N <br /> a <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 /> E <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 1 Q 1 Other:§ <br /> Comments ao u)AUI�YI �-��1� j Cl ' nra 1/" < <br /> W oI'D 0 No ;L 0lds V C�ALLCn1 <br /> o s �. 1. Fu�.c,►�i�U 1 S nU 'Onac�- it �y�� D�1. S;i'� I1�5��i�-� <br /> r _ Oose, -CPDD_ <br /> Inspection Form Included.Q <br /> Comments Included: Q <br /> Business Rep's Signature Phone Number Insp tor's Signature Phone Number <br /> INSTRUCTIONS ON BACK I Correct: Incorrect: 07q] EIXIAIMI PILIE1 111 2 3 62081 <br /> ® White Copy:CalRecycle Yellow Copy:Operator Pink Copy:LEA <br />