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Waste Tire Survey & Inspection Report Inspection Report Number <br /> CalRec cle State of California <br /> Y CalRecycle 181(Rev.10/10) Survey Form - 1 1230348 <br /> Dept.of Resources Recycling and Recovery(CalRecycle) Page 1 <br /> BLUE OR BLACK INK PEN <br /> Part A- survey----------- <br /> Business Profile Inspection Details <br /> TPID- Inspection Type(Fill one) <br /> Site Suffix: I® Routine Q Re-inspection Q Referral Q Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier: S an, 1�e a 011Lt Q CHP Q CalRecycle Q Complaint Q Educational Visit Q Other <br /> l <br /> Business or Facility Name Inspected By Inspector <br /> , <br /> 1` 1 Gl (`, n <br /> M k14M 2 _ (� <br /> Physical Address ' J v ( C S C�T�(� <br /> SQ-'7Z c . mb rSu <br /> C R C 2�� Inspection Date <br /> LO <br /> A J Time In Time Out <br /> Business Rep l— Title AM 10 AM <br /> i C 3 Q 0 PM � � � � O PM <br /> V`�U r•�l n �� 1(,1 <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 /> Q Active Q Passenger Q Generator Q Outdoor <br /> O ® Closed Q Alter <br /> GPS Latitude �� � <br /> O Q Inactive Q Truck Q Hauler Q Indoor <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 /> 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 ® 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 /> Q Q PRC§42956-Registration/Decal in Vehicle <br /> Q Q 14 CCR§18459-Responsible Entities Complying with Manifesting Requirements Date <br /> Q Q 14 CCR§18459.1 -Tire Program ID Number from CalRecycle <br /> Q Q 14 CCR§18 (Required for NOV or EXE 459.2.1 -Submittal of Comprehensive Trip Logs within 90 days <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 /> E <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:§ 1 <br /> Comments Ar .419 <br /> f1SU^ J1)jQ_ � <br /> 0 � �U1 (..lJ��� <br /> W(�5 *,A I��) dl iu,nit ras (,t 1�u<5 (� [.omacQr;rl. <br /> 1 <br /> Nom' �,'�� iS rn leS� vt�C2 No ?res, 0_ 5 <br /> InspectionForm Included: Q <br /> Comments Included: <br /> �"s Rep's Signature Phone Number �Innsjpor's Signature Phone Number <br /> 62081 <br /> INSTRUCTIONS ON BACKFCorrect:0Incorrect: � W E X AMP L E 1 2 3 <br /> White Copy:CalRecycle Yellow Copy:Operator Pink Copy:LEA <br />