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Waste Tire 5_.vey & Inspection Repoi - Inspection Report Number <br /> Cal Rec cle State of California /1 <br /> Y CalRecycle 181(Rev.10/10) Survey Form - Page 1 11 - 117 6 4 4 2 <br /> Dept.of Resources Recycling and Recovery(CalRecycle) <br /> Part A-Survey BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- Inspection Type(Fill one) <br /> Site Suffix: �, u O p �, �"� ( 0 Routine I& Re-inspection 0 Referral 0 Observation <br /> Local �G�� -\OC �1 4�]_ If Referral,choose referral type(Fill one) <br /> Identifier: U Y (,� ALJ/ 0 CHP 0 CalRecycle 0 Complaint 0 Educational Visit 0 Other <br /> Business or Facility Name Inspected By Inspector <br /> �e�ti��,� � L. . P - <br /> Physical Address <br /> Inspection Date <br /> Y-tL C_V� �� Time In Time Out <br /> Business Rep Title r� 0 AM Q AM <br /> ( I <br /> `� - C)V O PM � \ � AkPM <br /> Operational Status Tire Type Business Role Storage Type <br /> Tire Count (Whole/PTE) <br /> (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> � � <br /> le Active 0 Passenger 0 Generator 0 Outdoor <br /> 0 Closed 0 Altered <br /> GPS Latitude 0 Hauler Indoor <br /> O 0 Inactive *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 40 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 /> Notice Of Violation 0 Extension <br /> 0 0 PRC§42951 -Waste Tire Hauler Registration and Transport of Tires <br /> 0 0 PRC§42953-Contracts with Registered Waste Tire Haulers. Compliance Deadline <br /> 0 0 PRC§42956-Registration/Decal in Vehicle <br /> 00 14 CCR§18459-Responsible Entities Complying with Manifesting Requirements Date <br /> T / M / M <br /> 0 0 14 CCR§18459.1 -Tire Program ID Number from CalRecycle <br /> 0 0 14 CCR§18459.2.1 -Submittal of Comprehensive Trip Logs within 90 days (Required for NOV or EXl) N <br /> a <br /> 0 0 14 CCR§18459.3-Retention of Comprehensive Trip Logs for 3 years o <br /> 0 0 14 CCR§18460.2-Manifest System Requirements for Registered Waste Tire Haulers 0 Referred/CalRecycle Enforcement <br /> 0 0 14 CCR§18461 -Manifest System Requirements for Waste Tire End-Use Facilities W <br /> 0 0 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators ®In Compliance-No Violations o <br /> 0 1 0 1 Other:§ <br /> Comments <br /> Inspection Form Included: 0 2,617 SDZ-WS 7 `I <br /> Comments Included: g ?6 7 <br /> usiness Rep's Signature Phone Number I or Si nature Phone Number <br /> 62081 <br /> INSTRUCTIONS ON BACK Correct:• Incorrect: X [EX K I 1 2 3 <br /> White Copy:CalRecycle Yellow Copy:Operator Pink Cop :L ® ■ <br />