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2 Waste Tire Survey & Inspection Report Inspection Report Number <br /> CalRecycle State of cle181(R I 1 - 1230130 <br /> CalRecycle 181(Rev.10/1 0)y(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- / OInspection Type(Fill one) <br /> Site Suffix: (0 ® Routine 0 Re-inspection 0 Referral 0 Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier: San QC,��( J) L1�1 0 CHP 0 CalRecycle 0 Complaint 0 Educational Visit 0 Other <br /> Business or Facility Name II Inspected By Inspector <br /> Physical Address 3 � - 1 0 ) W <br /> O Ga^ <br /> CA fl57b S Inspection Date � / G <br /> Time In Time Out <br /> Business Rep Title l O AM ®AM <br /> ` D 0 0 PM O 0 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 /> ' �CJ 0 Active 0 Pass <br /> nger 0 Generator 0 Outdoor <br /> O ® Closed 0 AltereWA ( nn N <br /> GPS Latitude 0 HaulerA 0 Indd rr Y <br /> O 0 Inactive 0 Truck <br /> Longitude - 0 Planned 0 OTR 0 End-Use 0 Container <br /> Business Type(Fill all that apply) <br /> 0 New Tire Dealer 0 Auto Repair 0 Trucking Fleet 0 Government 0 Retreader 0 Dismantler 0 Tire Derived Fuel <br /> 0 Used Tire Dealer 0 Auto Body 0 Car Dealer 0 Collection 0 Crumb Rubber <br /> 0 Service Station 0 Hauler 0 Agriculture 0 Shredder 0 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 /> 0 0 PR §42 - 0 Notice Of Violation 0 Extension <br /> C 951 Waste Tire Hauler Registration and Transport of Tires <br /> 0 0 PRC§42953-Contracts with Registered Waste Tire Haulers. Compliance Deadline <br /> PRC§42956-Registration/Decal in Vehicle <br /> 0 0 14 CCR§18459-Responsible Entities Complying with Manifesting Requirements Date / m / m <br /> 0 0 14 CCR§18459.1 -Tire Program ID Number from CalRecycle a <br /> 0 0 14 CCR§18459.2.1 -Submittal of Comprehensive Trip Logs within 90 days (Required for NOV or EXE N <br /> 0 0 14 CCR§18459.3-Retention of Comprehensive Trip Logs for 3 years U) <br /> 0 <br /> 0 0 14 CCR§18460.2-Manifest System Requirements for Registered Waste Tire Haulers 0 Referred/CalRecycle Enforcement <br /> w <br /> 0 0 14 CCR§18461 -Manifest System Requirements for Waste Tire End-Use Facilities <br /> Other: In Compliance-No Violations o <br /> O O § <br /> Comments -rn � TO'1,, l � 7dkr l <br /> IT- 1 I I�14) <br /> UCkS <br /> [n <br /> Inspection Form Included: 0 <br /> Comments Included: 0 _ ul <br /> Business Rep's Signature Phone Number Insp or" Signature Phone Number <br /> INSTRUCTIONS ON BACK C7X4Y]Correct: Incorrect: E X A P E 1 2 3 62081 <br /> White Copy:CalRecycle Yellow Copy:Operator Pink C p :� <br />