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Oa Waste Tire Survey & Inspection Report Inspection Report Number ■ <br /> CalRec cle State of California <br /> Y CalRecycle 181(Rev.10/10) Survey Form - Page 1 I1 1242294 <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: 1 �D 1* Routine Q Re-inspection Q Referral Q Observation <br /> Local If Referral,choose referral type(Fill one) <br /> e <br /> Identifier: cto zoC� 1A1C� l J Q CHP Q CalRecycle Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name Inspected By Inspector <br /> ; <br /> M vp spun LL _ <br /> Physical ddre s \ p� L 31 1 O l CsCOTT a <br /> Inspection Date '), / I y <br /> SIA C)uv&to CA <br /> Time In Time Out <br /> Business Reyp� Title Q O AM O AM <br /> %6 IhOK '\ t= ® PM I 5 0 PM <br /> Operational Status Tire Type Business Role Storage Type <br /> /rV (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> Tire Count(Whole/PTE) l('d'1 <br /> ® Active Q Passenger ® Generator Q Outdoor <br /> O Q Closed Q Altered 014 <br /> GPS Latitude Q Hauler Q Indoor <br /> O Q Inactive ® Truck <br /> Longitude — Q Planned ® OTR Q End-Use Q Container <br /> Business Type(Fill all that apply) <br /> Q New Tire Dealer Q Auto Repair ® 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 1 l <br /> Q Service Station Q Hauler Q Agriculture Q Shredder ® Other Q 1$i"Jt 141_0n G(*rnr <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 <br /> Q Q 14 CCR§18459.1 -Tire Program ID Number from CalRecycle N <br /> Q Q 14 CCR§18459.2.1 -Submittal of Comprehensive Trip Logs within 90 days (Required for NOV or EXE N <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 /> 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 /> �0�L)JAI�w U�fn�a1"w1= <br /> ' JA+jonS 0i c,,f@,U S O� U c ern— <br /> Inspection Form Include Q <br /> Comments Inc lu ed: <br /> Business p's I ure Phone Number Ins ctor's Signature Phone Number <br /> INSTRUCTION K Correct: Incorrect: ?vE X AMP 1 2 3 62081 <br /> ■ White Copy:CalRecycle Yellow Copy:Operator Pink Co y: ® ■ <br />